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Prescription Intake
 
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Validate DEA #

Drug Pharmacy DAW Code
 

Drug Name

Manufacturer

 
Cost Per Unit  $
Unit Type  

 
NDC#

 
DEA Schedule   

SIG
Latin Terms & Common Abbreviations

Qty & Refills Quantity Prescribed   

 
Quantity To Dispense   

 
Days Supply   

 
Refills   

Dates Date Rx Dispensed   

 
Date Rx Written   

 
Date Rx Expires   

 
Use By   

 
Delivery Status   

 
Date/Time Due:   

Documentation Pharmacist Initials:   

 
Prescription Origin Code   

 
Serial Number   

 
Dispensing Fee   

Counseling Auxiliary Label #1   
      
Controlled Substance Required Statement:

Medication Guide is Provided:

Take with Food:

Take on an Empty Stomach:

Do Not Crush or Chew:

Finish All Medication (e.g. antibiotics):

Shake Well:

Keep Refrigerated (storage):

Avoid Alcohol:

 
REMOVE AUXILIARY LABEL:

 
Open Aux 1      Load Aux 1
Auxiliary Label #2   
      
Open Aux 2      Load Aux 2
Auxiliary Label #3   
      
Open Aux 3      Load Aux 3
Auxiliary Label #4   
      
Open Aux 4      Load Aux 4
 
Custom Patient Information