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Prescription Intake
Patient
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*New Patient
Bontrager, Stanley M.
Bontrager, Coleen L.
Bontrager, Julia M.
Bontrager, David M.
Bontrager, Joel N.
Bontrager, Rose J.
Bruno, Kyle O.
Bruno, Elizabeth R.
Bruno, Billy Joe
Day, Daniel
Day, Gloria
Elder, Robert
Elder, Georgia L.
Elder, Charles O.
Elder, Laurie N.
Elder, Mrs. Harold
Garcia, Carlos
Garcia, Andrea
Garcia, Gabriela
Garcia, María
Garcia, Juan
Hanson, Richard T.
Hanson, Lily M.
Hanson, James R.
Hanson, William B.
Hanson, Mary Jean
Johnson, Elmer
Johnson, Evelyn
Jones, William P.
Jones, Sylvia F.
Jones, Janet T.
Khan, Omar
Khan, Fayrah
Khan, Phoebe
Miller, Edward M.
Miller, Judy J.
Miller, Jim S.
Miller, Jill J.
Moore, George S.
Moore, Betty L.
Moore, Wendy J.
Moore, Anna
Morgan, John R.
Morgan, Margaret
Morgan, Hilda R.
Mott, Edward G.
Mott, Mary F.
Mott, Jim O.
Mott, Jill S.
Mott, Tim D.
Mott, Julie
Nguyen, Van
Nguyen, Trang
Nguyen, Tran
Nguyen, Anh
Nguyen, Duc
Nguyen, Ngoc
Nguyen, Nhi
Roberts, Roberta
Roberts, Robert
Roberts, Robbie
Roberts, Robin
Sawyer, Mark
Sawyer, Alice
Sykes, Bob O.
Sykes, Teresa C.
Williams, Alexander
Williams, Beverly
Williams, William
Williams, Gina
Williams, Audrey
Wong, Zhang
Wong, Sunny
Wong, Lily
Wong, Li
Wright, Don Q.
Wright, Elizabeth A.
Wright, Mary S.
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Use Safety Caps?:
Prescription Insurance:
Cash - no third party insurance
Third Party Insurance/Coupon
Prescriber
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*New Prescriber
Carolyn Abman
Samuel Bernstein
Sherman F. Fleer, DDS
Harold L. Green
Sandra Jones
Norman Keyes
Cynthia McDonald
George Platz
Royal T. Shumway
James T. Warren
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Drug
Pharmacy DAW Code
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0 - No Product Selection Indicated
1 - Substitution Not Allowed by Prescriber
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2 - Substitution Allowed-Patient Requested Product Dispensed
3 - Substitution Allowed-Pharmacist Selected Product Dispensed
4 - Substitution Allowed-Generic Drug Not in Stock
5 - Substitution Allowed-Brand Drug Dispensed as a Generic
6 - Override
7 - Substitution Not Allowed-Brand Drug Mandated by Law
8 - Substitution Allowed-Generic Drug Not Available in Marketplace
9 - Substitution Allowed By Prescriber but Plan Requests Brand
Drug Name
Manufacturer
Cost Per Unit
$
Unit Type
each (units)
mL
gram
milligram
international unit
NDC#
DEA Schedule
Not a Controlled Substance
CII
CIII
CIV
CV
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
Waiting
Pickup
Delivery
Date/Time Due:
Documentation
Pharmacist Initials:
Prescription Origin Code
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1 - Written
2 - Telephone
3 - Electronic
4 - Facsimile
5 - Pharmacy Transfer
5 - Pharmacy
Serial Number
Dispensing Fee
Counseling
Auxiliary Label #1
Controlled Substance Required Statement:
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Auxiliary Label #1
Auxiliary Label #2
Auxiliary Label #3
Auxiliary Label #4
Medication Guide is Provided:
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Auxiliary Label #1
Auxiliary Label #2
Auxiliary Label #3
Auxiliary Label #4
Take with Food:
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Auxiliary Label #1
Auxiliary Label #2
Auxiliary Label #3
Auxiliary Label #4
Take on an Empty Stomach:
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Auxiliary Label #1
Auxiliary Label #2
Auxiliary Label #3
Auxiliary Label #4
Do Not Crush or Chew:
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Auxiliary Label #1
Auxiliary Label #2
Auxiliary Label #3
Auxiliary Label #4
Finish All Medication (e.g. antibiotics):
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Auxiliary Label #1
Auxiliary Label #2
Auxiliary Label #3
Auxiliary Label #4
Shake Well:
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Auxiliary Label #1
Auxiliary Label #2
Auxiliary Label #3
Auxiliary Label #4
Keep Refrigerated (storage):
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Auxiliary Label #1
Auxiliary Label #2
Auxiliary Label #3
Auxiliary Label #4
Avoid Alcohol:
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Auxiliary Label #1
Auxiliary Label #2
Auxiliary Label #3
Auxiliary Label #4
REMOVE AUXILIARY LABEL:
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Auxiliary Label #1
Auxiliary Label #2
Auxiliary Label #3
Auxiliary Label #4
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