Free 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

• Known Allergies: Penicillin

• Any Other Contraindications: Avoid use with potassium supplements without consultation.

Substitution Permitted:

• Yes

• No

Generic Substitution:

• Yes

• No

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.

Prescription Templates @ Template.net