Prescribed Medication
Prescription Date: 08/12/2080
Prescription Number: RX-2080-987654
I. Patient Information
Patient Name: Nadette Ritchie
Date of Birth: 04/15/2050
Patient Address: Salem, OR 97301
Phone Number: 222 555 7777
Email Address: nadette@you.mail
II. Prescribing Physician Information
Physician Name: Dr. [YOUR NAME]
Physician License Number: 1234567890
Practice Name: [YOUR COMPANY NAME]
Address: [YOUR COMPANY ADDRESS]
Phone Number: [YOUR COMPANY NUMBER]
Email Address: [YOUR EMAIL]
III. Medication Details
Medication Name: Lisinopril
Dosage Strength: 10 mg
Dosage Form: Tablet
Quantity to Dispense: 30 tablets
Refills: 2
Directions for Use: Take 1 tablet orally once daily with water.
IV. Additional Instructions or Information
Monitor blood pressure regularly and report any significant changes.
V. Allergies/Warnings
Substitution Permitted:
Generic Substitution:
VI. Follow-Up Appointment
Date: 09/12/2080
Time: 2:30 PM
Prescribing Physician’s Signature:
Date: 08/12/2080
This prescription is valid until 12/12/2080 unless otherwise stated.
Important Notice:
This prescription is for the indicated patient only. Sharing this medication with others or improper use is strictly prohibited.
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