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SAMPLE MEDICATION SHEET
Patient name DOB or chart number
Allergy or Rxn to
Symptom
Allergy or Rxn to
Symptom
Date Medication Dose Route Frequency No Recall # Indication D/C Date
(Once approved and refilled, attach top edge of first request slip on this line)
(Second medication request slip)
(Third medication request slip)
(Fourth medication request slip)
Medication Request Slip
Slips are sized to overlap, exposing only medications and disposition of request(s)
Patient name DOB or chart number
Date/time of request / / AM/PM
Pharmacy
Patient’s MD/PA
Phone number
Medication Dose Route Frequency Quantity Last fill Number of fills Signature for Authorization
1. _________________ ________ _______ __________ _________ ________ _______________ _________________________________________________________
2. _________________ ________ ______ __________ _________ ________ _______________ __________________________________________________________
3. _________________ ________----_______ __________ _________ _________ _______________ __________________________________________________________
Do NOT refill #
Needs appointment for # Date/time of call / / AM/PM
Note
Initials
Source: The Professional Liability Handbook. American Academy of Physician Assistants, 1990.
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