1 / 27

University of Washington Pharmaceutical Care Center Prescription Form

Prescription form template for University of Washington Pharmaceutical Care Learning Center. Fill in patient details, medication information, and prescriber details to authorize prescription.

charla
Télécharger la présentation

University of Washington Pharmaceutical Care Center Prescription Form

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. New & Transfer Rx Dr. Allen Pharm 585 January 4th 2011

  2. New Rx

  3. University of Washington Pharmaceutical Care Learning Center 1959 NE Pacific Street, Room T484 Seattle, WA 98195-7630 (206) 616-9867 Date____________________________ Name______________________________________________________ Address____________________________________________________ Phone______________________________________________________ Date of Birth________________________________________________  Substitution permitted.__________________________________ Dispense as written.______________________________________________________ REFILL______________TIMES DEA No. __________________________________________________________________ Prescriber phone___________________________ Prescriber address _______________________________________________________ PHONED BY____________________________________________ RECEIVED BY_____________________________________________________________

  4. University of Washington Pharmaceutical Care Learning Center 1959 NE Pacific Street, Room T484 Seattle, WA 98195-7630 (206) 616-9867 Date____________________________ Name________________________________ Address____________________________________________________ Phone______________________________________________________ Date of Birth________________________________________________  Substitution permitted.__________________________________ Dispense as written.______________________________________________________ REFILL______________TIMES DEA No. __________________________________________________________________ Prescriber phone___________________________ Prescriber address _______________________________________________________ PHONED BY____________________________________________ RECEIVED BY_____________________________________________________________

  5. University of Washington Pharmaceutical Care Learning Center 1959 NE Pacific Street, Room T484 Seattle, WA 98195-7630 (206) 616-9867 Date____________________________ Name______________________________________________________ Address____________________________________________________ Phone______________________________________________________ Date of Birth_________________________  Substitution permitted.__________________________________ Dispense as written.______________________________________________________ REFILL______________TIMES DEA No. __________________________________________________________________ Prescriber phone___________________________ Prescriber address _______________________________________________________ PHONED BY____________________________________________ RECEIVED BY_____________________________________________________________

  6. University of Washington Pharmaceutical Care Learning Center 1959 NE Pacific Street, Room T484 Seattle, WA 98195-7630 (206) 616-9867 Date____________________ Name______________________________________________________ Address____________________________________________________ Phone______________________________________________________ Date of Birth________________________________________________  Substitution permitted.__________________________________ Dispense as written.______________________________________________________ REFILL______________TIMES DEA No. __________________________________________________________________ Prescriber phone___________________________ Prescriber address _______________________________________________________ PHONED BY____________________________________________ RECEIVED BY_____________________________________________________________

  7. University of Washington Pharmaceutical Care Learning Center 1959 NE Pacific Street, Room T484 Seattle, WA 98195-7630 (206) 616-9867 Date____________________________ Name______________________________________________________ Address____________________________________________________ Phone______________________________________________________ Date of Birth________________________________________________  Drug, Strength, Quantity Substitution permitted.__________________________________ Dispense as written.______________________________________________________ REFILL______________TIMES DEA No. __________________________________________________________________ Prescriber phone___________________________ Prescriber address _______________________________________________________ PHONED BY____________________________________________ RECEIVED BY_____________________________________________________________

  8. University of Washington Pharmaceutical Care Learning Center 1959 NE Pacific Street, Room T484 Seattle, WA 98195-7630 (206) 616-9867 Date____________________________ Name______________________________________________________ Address____________________________________________________ Phone______________________________________________________ Date of Birth________________________________________________  Drug, Strength, Quantity SIG Substitution permitted.__________________________________ Dispense as written.______________________________________________________ REFILL______________TIMES DEA No. __________________________________________________________________ Prescriber phone___________________________ Prescriber address _______________________________________________________ PHONED BY____________________________________________ RECEIVED BY_____________________________________________________________

  9. University of Washington Pharmaceutical Care Learning Center 1959 NE Pacific Street, Room T484 Seattle, WA 98195-7630 (206) 616-9867 Date____________________________ Name______________________________________________________ Address____________________________________________________ Phone______________________________________________________ Date of Birth________________________________________________  Drug, Strength, Quantity SIG Substitution permitted.__________________ Dispense as written.________________ REFILL______________TIMES DEA No. __________________________________________________________________ Prescriber phone___________________________ Prescriber address _______________________________________________________ PHONED BY____________________________________________ RECEIVED BY_____________________________________________________________

  10. University of Washington Pharmaceutical Care Learning Center 1959 NE Pacific Street, Room T484 Seattle, WA 98195-7630 (206) 616-9867 Date____________________________ Name______________________________________________________ Address____________________________________________________ Phone______________________________________________________ Date of Birth________________________________________________  Drug, Strength, Quantity SIG Substitution permitted.__________________________________ Dispense as written.______________________________________________________ REFILL______________TIMES DEA No. __________________________________________________________________ Prescriber phone___________________________ Prescriber address _______________________________________________________ PHONED BY____________________________________________ RECEIVED BY_____________________________________________________________

  11. University of Washington Pharmaceutical Care Learning Center 1959 NE Pacific Street, Room T484 Seattle, WA 98195-7630 (206) 616-9867 Date____________________________ Name______________________________________________________ Address____________________________________________________ Phone______________________________________________________ Date of Birth________________________________________________  Drug, Strength, Quantity SIG Substitution permitted.__________________________________ Dispense as written.______________________________________________________ REFILL______________TIMES DEA No. ________________________________ Prescriber phone___________________________Prescriber address _______________________________________________________ PHONED BY____________________________________________ RECEIVED BY_____________________________________________________________

  12. University of Washington Pharmaceutical Care Learning Center 1959 NE Pacific Street, Room T484 Seattle, WA 98195-7630 (206) 616-9867 Date____________________________ Name______________________________________________________ Address____________________________________________________ Phone______________________________________________________ Date of Birth________________________________________________  Drug, Strength, Quantity SIG Substitution permitted.__________________________________ Dispense as written.______________________________________________________ REFILL______________TIMES DEA No. __________________________________________________________________ Prescriber phone________________ Prescriber address _______________________________________________________ PHONED BY____________________________________________ RECEIVED BY_____________________________________________________________

  13. University of Washington Pharmaceutical Care Learning Center 1959 NE Pacific Street, Room T484 Seattle, WA 98195-7630 (206) 616-9867 Date____________________________ Name______________________________________________________ Address____________________________________________________ Phone______________________________________________________ Date of Birth________________________________________________  Drug, Strength, Quantity SIG Substitution permitted.__________________________________ Dispense as written.______________________________________________________ REFILL______________TIMES DEA No. __________________________________________________________________ Prescriber phone___________________________ Prescriber address _______________________________________________________ PHONED BY____________________________ RECEIVED BY_____________________________________________________________

  14. University of Washington Pharmaceutical Care Learning Center 1959 NE Pacific Street, Room T484 Seattle, WA 98195-7630 (206) 616-9867 Date____________________________ Name______________________________________________________ Address____________________________________________________ Phone______________________________________________________ Date of Birth________________________________________________  Drug, Strength, Quantity SIG Substitution permitted.__________________________________ Dispense as written.______________________________________________________ REFILL______________TIMES DEA No. __________________________________________________________________ Prescriber phone___________________________ Prescriber address _______________________________________________________ PHONED BY____________________________________________ RECEIVED BY________________________________________

  15. University of Washington Pharmaceutical Care Learning Center 1959 NE Pacific Street, Room T484 Seattle, WA 98195-7630 (206) 616-9867 Date____________________________ Name______________________________________________________ Address____________________________________________________ Phone______________________________________________________ Date of Birth________________________________________________  Drug, Strength, Quantity SIG Substitution permitted.__________________________________ Dispense as written.______________________________________________________ REFILL______________TIMES DEA No. __________________________________________________________________ Prescriber phone___________________________ Prescriber address _______________________________________________________ PHONED BY____________________________________________ RECEIVED BY________________________________________ RBVO

  16. Transfer Rx

  17. University of Washington Pharmaceutical Care Learning Center 1959 NE Pacific Street, Room T484 Seattle, WA 98195-7630 (206) 616-9867 Date____________________________ NAME______________________________________________________ ADDRESS__________________________________________________ PHONE____________________________________________________ DATE OF BIRTH____________________________________________  Drug, Strength, Quantity SIG Substitution permitted.__________________________________ Dispense as written.______________________________________________________ REFILL______________TIMESDEA No. __________________________________________________________________ Prescriber phone___________________________ Prescriber address _______________________________________________________ PHONED BY____________________________________________ RECEIVED BY_____________________________________________________________

  18. University of Washington Pharmaceutical Care Learning Center 1959 NE Pacific Street, Room T484 Seattle, WA 98195-7630 (206) 616-9867 Date____________________________ NAME______________________________________________________ ADDRESS__________________________________________________ PHONE____________________________________________________ DATE OF BIRTH____________________________________________  Drug, Strength, Quantity SIG Substitution permitted.__________________________________ Dispense as written.______________________________________________________ REFILL______________TIMESDEA No. __________________________________________________________________ Prescriber phone___________________________ Prescriber address _______________________________________________________ PHONED BY____________________________________________ RECEIVED BY_____________________________________________________________ Transfer

  19. University of Washington Pharmaceutical Care Learning Center 1959 NE Pacific Street, Room T484 Seattle, WA 98195-7630 (206) 616-9867 Date____________________________ NAME______________________________________________________ ADDRESS__________________________________________________ PHONE____________________________________________________ DATE OF BIRTH____________________________________________  Drug, Strength, Quantity SIG Substitution permitted.__________________________________ Dispense as written.______________________________________________________ REFILL______________TIMESDEA No. __________________________________________________________________ Prescriber phone___________________________ Prescriber address _______________________________________________________ PHONED BY____________________________________________ RECEIVED BY_____________________________________________________________ Transfer Original Rx#:

  20. University of Washington Pharmaceutical Care Learning Center 1959 NE Pacific Street, Room T484 Seattle, WA 98195-7630 (206) 616-9867 Date____________________________ NAME______________________________________________________ ADDRESS__________________________________________________ PHONE____________________________________________________ DATE OF BIRTH____________________________________________  Drug, Strength, Quantity SIG Substitution permitted.__________________________________ Dispense as written.______________________________________________________ REFILL______________TIMESDEA No. __________________________________________________________________ Prescriber phone___________________________ Prescriber address _______________________________________________________ PHONED BY____________________________________________ RECEIVED BY_____________________________________________________________ Transfer Original Rx#: Original Date Written:

  21. University of Washington Pharmaceutical Care Learning Center 1959 NE Pacific Street, Room T484 Seattle, WA 98195-7630 (206) 616-9867 Date____________________________ NAME______________________________________________________ ADDRESS__________________________________________________ PHONE____________________________________________________ DATE OF BIRTH____________________________________________  Drug, Strength, Quantity SIG Substitution permitted.__________________________________ Dispense as written.______________________________________________________ REFILL______________TIMESDEA No. __________________________________________________________________ Prescriber phone___________________________ Prescriber address _______________________________________________________ PHONED BY____________________________________________ RECEIVED BY_____________________________________________________________ Transfer Original Rx#: Original Date Written: Last Fill Date:

  22. University of Washington Pharmaceutical Care Learning Center 1959 NE Pacific Street, Room T484 Seattle, WA 98195-7630 (206) 616-9867 Date____________________________ NAME______________________________________________________ ADDRESS__________________________________________________ PHONE____________________________________________________ DATE OF BIRTH____________________________________________  Drug, Strength, Quantity SIG Substitution permitted.__________________________________ Dispense as written.______________________________________________________ REFILL______________TIMESDEA No. __________________________________________________________________ Prescriber phone___________________________ Prescriber address _______________________________________________________ PHONED BY____________________________________________ RECEIVED BY_____________________________________________________________ Transfer Original Rx#: Original Date Written: Last Fill Date: Refills Remaining:

  23. University of Washington Pharmaceutical Care Learning Center 1959 NE Pacific Street, Room T484 Seattle, WA 98195-7630 (206) 616-9867 Date____________________________ NAME______________________________________________________ ADDRESS__________________________________________________ PHONE____________________________________________________ DATE OF BIRTH____________________________________________  Drug, Strength, Quantity SIG Substitution permitted.__________________________________ Dispense as written.______________________________________________________ REFILL______________TIMESDEA No. __________________________________________________________________ Prescriber phone___________________________ Prescriber address _______________________________________________________ PHONED BY____________________________________________ RECEIVED BY_____________________________________________________________ Transfer Original Rx#: Original Date Written: Last Fill Date: Refills Remaining: Name & Address of Pharmacy

  24. University of Washington Pharmaceutical Care Learning Center 1959 NE Pacific Street, Room T484 Seattle, WA 98195-7630 (206) 616-9867 Date____________________________ NAME______________________________________________________ ADDRESS__________________________________________________ PHONE____________________________________________________ DATE OF BIRTH____________________________________________  Drug, Strength, Quantity SIG Substitution permitted.__________________________________ Dispense as written.______________________________________________________ REFILL______________TIMESDEA No. __________________________________________________________________ Prescriber phone___________________________ Prescriber address _______________________________________________________ PHONED BY____________________________________________ RECEIVED BY_____________________________________________________________ Transfer Original Rx#: Original Date Written: Last Fill Date: Refills Remaining: Name & Address of Pharmacy Phone #:

  25. University of Washington Pharmaceutical Care Learning Center 1959 NE Pacific Street, Room T484 Seattle, WA 98195-7630 (206) 616-9867 Date____________________________ NAME______________________________________________________ ADDRESS__________________________________________________ PHONE____________________________________________________ DATE OF BIRTH____________________________________________  Drug, Strength, Quantity SIG Substitution permitted.__________________________________ Dispense as written.______________________________________________________ REFILL______________TIMESDEA No. __________________________________________________________________ Prescriber phone___________________________ Prescriber address _______________________________________________________ PHONED BY____________________________________________ RECEIVED BY_____________________________________________________________ Transfer Original Rx#: Original Date Written: Last Fill Date: Refills Remaining: Name & Address of Pharmacy: Phone #: RPh:

  26. University of Washington Pharmaceutical Care Learning Center 1959 NE Pacific Street, Room T484 Seattle, WA 98195-7630 (206) 616-9867 Date____________________________ NAME______________________________________________________ ADDRESS__________________________________________________ PHONE____________________________________________________ DATE OF BIRTH____________________________________________  Drug, Strength, Quantity SIG Substitution permitted.__________________________________ Dispense as written.______________________________________________________ REFILL______________TIMESDEA No. __________________________________________________________________ Prescriber phone___________________________Prescriber address _______________________________________________________ PHONED BY____________________________________________ RECEIVED BY_____________________________________________________________ Transfer Original Rx#: Original Date Written: Last Fill Date: Refills Remaining: Name & Address of Pharmacy: Phone #: RPh: Pharmacy DEA #:

  27. University of Washington Pharmaceutical Care Learning Center 1959 NE Pacific Street, Room T484 Seattle, WA 98195-7630 (206) 616-9867 Date____________________________ NAME______________________________________________________ ADDRESS__________________________________________________ PHONE____________________________________________________ DATE OF BIRTH____________________________________________  Drug, Strength, Quantity SIG Substitution permitted.__________________________________ Dispense as written.______________________________________________________ REFILL______________TIMESDEA No. __________________________________________________________________ Prescriber phone___________________________Prescriber address _______________________________________________________ PHONED BY____________________________________________ RECEIVED BY_____________________________________________________________ RBVO Transfer Original Rx#: Original Date Written: Last Fill Date: Refills Remaining: Name & Address of Pharmacy: Phone #: RPh: Pharmacy DEA #:

More Related