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Medicine Chart
Name: ____________________________
Date: ____________________________
NAME OF MEDICINE COLOR WHAT S IT FOR? DOSE
HOW OFTEN &
WHAT TIME
PRESCRIBING
DOCTOR
PHARMACY
PHONE NO.
SPECIAL INSTRUCTIONS REFILL DATE
Aspirin white blood thinner 1 pill
once daily at night
Dr. Jones
650-555-1234
Take with food 9/1/12
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