Professional Pharmaceutical Prescription
I. Prescriber's Information
Full Name: | [YOUR NAME] |
License Number: | 12345678 |
Contact Number: | 222 555 7777 |
Email Address: | [YOUR EMAIL] |
Address: | Dallas, TX 85224 |
II. Patient Information
Full Name: | Marcelo Green |
Date of Birth: | 01/01/2050 |
Contact Number: | 222 555 7777 |
Email Address: | marcelo@you.mail |
Address: | Dallas, TX 85224 |
III. Medication Details
Medication Name: | Amoxicillin |
Dosage: | 500 mg |
Frequency: | Take one capsule every 8 hours. |
Route of Administration: | Take one capsule by mouth every 8 hours for 10 days. |
Duration: | 10 days |
Quantity: | 30 capsules |
IV. Diagnosis
Please provide a brief description of the diagnosis related to this prescription:
V. Additional Instructions
If there are any specific instructions for this prescription, list them below:
VI. Prescriber's Signature
Signature:
Date: 08/11/2082
Please ensure that all sections are completed before submission. Retain a copy for your records.
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