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Prescription Intake
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Validate DEA #

Drug Pharmacy DAW Code

Drug Name


Cost Per Unit  $
Unit Type  


DEA Schedule   

Latin Terms & Common Abbreviations

Qty & Refills Quantity Prescribed   

Quantity To Dispense   

Days Supply   


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:


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