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New & Transfer Rx Dr. Allen Pharm 585 January 4 th 2011
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New & Transfer Rx
Dr. Allen
Pharm 585
January 4th 2011
New Rx
University of WashingtonPharmaceutical Care Learning Center
1959 NE Pacific Street, Room T484Seattle, WA 98195-7630
(206) 616-9867
Date____________________________Name______________________________________________________
Address____________________________________________________ Phone______________________________________________________ Date of Birth________________________________________________
Substitution permitted.__________________________________ Dispense as written.______________________________________________________
REFILL______________TIMES DEA No. __________________________________________________________________ Prescriber phone___________________________ Prescriber address _______________________________________________________ PHONED BY____________________________________________ RECEIVED BY_____________________________________________________________
University of WashingtonPharmaceutical Care Learning Center
1959 NE Pacific Street, Room T484Seattle, WA 98195-7630
(206) 616-9867
Date____________________________
Name________________________________
Address____________________________________________________ Phone______________________________________________________ Date of Birth________________________________________________
Substitution permitted.__________________________________ Dispense as written.______________________________________________________
REFILL______________TIMES DEA No. __________________________________________________________________ Prescriber phone___________________________ Prescriber address _______________________________________________________ PHONED BY____________________________________________ RECEIVED BY_____________________________________________________________
University of WashingtonPharmaceutical Care Learning Center
1959 NE Pacific Street, Room T484Seattle, WA 98195-7630
(206) 616-9867
Date____________________________Name______________________________________________________
Address____________________________________________________ Phone______________________________________________________
Date of Birth_________________________
Substitution permitted.__________________________________ Dispense as written.______________________________________________________
REFILL______________TIMES DEA No. __________________________________________________________________ Prescriber phone___________________________ Prescriber address _______________________________________________________ PHONED BY____________________________________________ RECEIVED BY_____________________________________________________________
University of WashingtonPharmaceutical Care Learning Center
1959 NE Pacific Street, Room T484Seattle, WA 98195-7630
(206) 616-9867
Date____________________Name______________________________________________________
Address____________________________________________________ Phone______________________________________________________ Date of Birth________________________________________________
Substitution permitted.__________________________________ Dispense as written.______________________________________________________
REFILL______________TIMES DEA No. __________________________________________________________________ Prescriber phone___________________________ Prescriber address _______________________________________________________ PHONED BY____________________________________________ RECEIVED BY_____________________________________________________________
University of WashingtonPharmaceutical Care Learning Center
1959 NE Pacific Street, Room T484Seattle, WA 98195-7630
(206) 616-9867
Date____________________________Name______________________________________________________
Address____________________________________________________ Phone______________________________________________________ Date of Birth________________________________________________
Drug, Strength, Quantity
Substitution permitted.__________________________________ Dispense as written.______________________________________________________
REFILL______________TIMES DEA No. __________________________________________________________________ Prescriber phone___________________________ Prescriber address _______________________________________________________ PHONED BY____________________________________________ RECEIVED BY_____________________________________________________________
University of WashingtonPharmaceutical Care Learning Center
1959 NE Pacific Street, Room T484Seattle, WA 98195-7630
(206) 616-9867
Date____________________________Name______________________________________________________
Address____________________________________________________ Phone______________________________________________________ Date of Birth________________________________________________
Drug, Strength, Quantity
SIG
Substitution permitted.__________________________________ Dispense as written.______________________________________________________
REFILL______________TIMES DEA No. __________________________________________________________________ Prescriber phone___________________________ Prescriber address _______________________________________________________ PHONED BY____________________________________________ RECEIVED BY_____________________________________________________________
University of WashingtonPharmaceutical Care Learning Center
1959 NE Pacific Street, Room T484Seattle, WA 98195-7630
(206) 616-9867
Date____________________________Name______________________________________________________
Address____________________________________________________ Phone______________________________________________________ Date of Birth________________________________________________
Drug, Strength, Quantity
SIG
Substitution permitted.__________________ Dispense as written.________________
REFILL______________TIMES DEA No. __________________________________________________________________ Prescriber phone___________________________ Prescriber address _______________________________________________________ PHONED BY____________________________________________ RECEIVED BY_____________________________________________________________
University of WashingtonPharmaceutical Care Learning Center
1959 NE Pacific Street, Room T484Seattle, WA 98195-7630
(206) 616-9867
Date____________________________Name______________________________________________________
Address____________________________________________________ Phone______________________________________________________ Date of Birth________________________________________________
Drug, Strength, Quantity
SIG
Substitution permitted.__________________________________ Dispense as written.______________________________________________________
REFILL______________TIMES DEA No. __________________________________________________________________ Prescriber phone___________________________ Prescriber address _______________________________________________________ PHONED BY____________________________________________ RECEIVED BY_____________________________________________________________
University of WashingtonPharmaceutical Care Learning Center
1959 NE Pacific Street, Room T484Seattle, WA 98195-7630
(206) 616-9867
Date____________________________Name______________________________________________________
Address____________________________________________________ Phone______________________________________________________ Date of Birth________________________________________________
Drug, Strength, Quantity
SIG
Substitution permitted.__________________________________ Dispense as written.______________________________________________________
REFILL______________TIMES DEA No. ________________________________ Prescriber phone___________________________ Prescriber address _______________________________________________________ PHONED BY____________________________________________ RECEIVED BY_____________________________________________________________
University of WashingtonPharmaceutical Care Learning Center
1959 NE Pacific Street, Room T484Seattle, WA 98195-7630
(206) 616-9867
Date____________________________Name______________________________________________________
Address____________________________________________________ Phone______________________________________________________ Date of Birth________________________________________________
Drug, Strength, Quantity
SIG
Substitution permitted.__________________________________ Dispense as written.______________________________________________________
REFILL______________TIMES DEA No. __________________________________________________________________
Prescriber phone________________ Prescriber address _______________________________________________________ PHONED BY____________________________________________ RECEIVED BY_____________________________________________________________
University of WashingtonPharmaceutical Care Learning Center
1959 NE Pacific Street, Room T484Seattle, WA 98195-7630
(206) 616-9867
Date____________________________Name______________________________________________________
Address____________________________________________________ Phone______________________________________________________ Date of Birth________________________________________________
Drug, Strength, Quantity
SIG
Substitution permitted.__________________________________ Dispense as written.______________________________________________________
REFILL______________TIMES DEA No. __________________________________________________________________ Prescriber phone___________________________ Prescriber address _______________________________________________________
PHONED BY____________________________ RECEIVED BY_____________________________________________________________
University of WashingtonPharmaceutical Care Learning Center
1959 NE Pacific Street, Room T484Seattle, WA 98195-7630
(206) 616-9867
Date____________________________Name______________________________________________________
Address____________________________________________________ Phone______________________________________________________ Date of Birth________________________________________________
Drug, Strength, Quantity
SIG
Substitution permitted.__________________________________ Dispense as written.______________________________________________________
REFILL______________TIMES DEA No. __________________________________________________________________ Prescriber phone___________________________ Prescriber address _______________________________________________________
PHONED BY____________________________________________ RECEIVED BY________________________________________
University of WashingtonPharmaceutical Care Learning Center
1959 NE Pacific Street, Room T484Seattle, WA 98195-7630
(206) 616-9867
Date____________________________Name______________________________________________________
Address____________________________________________________ Phone______________________________________________________ Date of Birth________________________________________________
Drug, Strength, Quantity
SIG
Substitution permitted.__________________________________ Dispense as written.______________________________________________________
REFILL______________TIMES DEA No. __________________________________________________________________ Prescriber phone___________________________ Prescriber address _______________________________________________________ PHONED BY____________________________________________ RECEIVED BY________________________________________
RBVO
Transfer Rx
University of WashingtonPharmaceutical Care Learning Center
1959 NE Pacific Street, Room T484Seattle, WA 98195-7630
(206) 616-9867
Date____________________________NAME______________________________________________________
ADDRESS__________________________________________________ PHONE____________________________________________________ DATE OF BIRTH____________________________________________
Drug, Strength, Quantity
SIG
Substitution permitted.__________________________________ Dispense as written.______________________________________________________
REFILL______________TIMES DEA No. __________________________________________________________________ Prescriber phone___________________________ Prescriber address _______________________________________________________ PHONED BY____________________________________________ RECEIVED BY_____________________________________________________________
University of WashingtonPharmaceutical Care Learning Center
1959 NE Pacific Street, Room T484Seattle, WA 98195-7630
(206) 616-9867
Date____________________________NAME______________________________________________________
ADDRESS__________________________________________________ PHONE____________________________________________________ DATE OF BIRTH____________________________________________
Drug, Strength, Quantity
SIG
Substitution permitted.__________________________________ Dispense as written.______________________________________________________
REFILL______________TIMES DEA No. __________________________________________________________________ Prescriber phone___________________________ Prescriber address _______________________________________________________ PHONED BY____________________________________________ RECEIVED BY_____________________________________________________________
Transfer
University of WashingtonPharmaceutical Care Learning Center
1959 NE Pacific Street, Room T484Seattle, WA 98195-7630
(206) 616-9867
Date____________________________NAME______________________________________________________
ADDRESS__________________________________________________ PHONE____________________________________________________ DATE OF BIRTH____________________________________________
Drug, Strength, Quantity
SIG
Substitution permitted.__________________________________ Dispense as written.______________________________________________________
REFILL______________TIMES DEA No. __________________________________________________________________ Prescriber phone___________________________ Prescriber address _______________________________________________________ PHONED BY____________________________________________ RECEIVED BY_____________________________________________________________
Transfer
Original Rx#:
University of WashingtonPharmaceutical Care Learning Center
1959 NE Pacific Street, Room T484Seattle, WA 98195-7630
(206) 616-9867
Date____________________________NAME______________________________________________________
ADDRESS__________________________________________________ PHONE____________________________________________________ DATE OF BIRTH____________________________________________
Drug, Strength, Quantity
SIG
Substitution permitted.__________________________________ Dispense as written.______________________________________________________
REFILL______________TIMES DEA No. __________________________________________________________________ Prescriber phone___________________________ Prescriber address _______________________________________________________ PHONED BY____________________________________________ RECEIVED BY_____________________________________________________________
Transfer
Original Rx#:Original Date Written:
University of WashingtonPharmaceutical Care Learning Center
1959 NE Pacific Street, Room T484Seattle, WA 98195-7630
(206) 616-9867
Date____________________________NAME______________________________________________________
ADDRESS__________________________________________________ PHONE____________________________________________________ DATE OF BIRTH____________________________________________
Drug, Strength, Quantity
SIG
Substitution permitted.__________________________________ Dispense as written.______________________________________________________
REFILL______________TIMES DEA No. __________________________________________________________________ Prescriber phone___________________________ Prescriber address _______________________________________________________ PHONED BY____________________________________________ RECEIVED BY_____________________________________________________________
Transfer
Original Rx#:Original Date Written:Last Fill Date:
University of WashingtonPharmaceutical Care Learning Center
1959 NE Pacific Street, Room T484Seattle, WA 98195-7630
(206) 616-9867
Date____________________________NAME______________________________________________________
ADDRESS__________________________________________________ PHONE____________________________________________________ DATE OF BIRTH____________________________________________
Drug, Strength, Quantity
SIG
Substitution permitted.__________________________________ Dispense as written.______________________________________________________
REFILL______________TIMES DEA No. __________________________________________________________________ Prescriber phone___________________________ Prescriber address _______________________________________________________ PHONED BY____________________________________________ RECEIVED BY_____________________________________________________________
Transfer
Original Rx#:Original Date Written:Last Fill Date:Refills Remaining:
University of WashingtonPharmaceutical Care Learning Center
1959 NE Pacific Street, Room T484Seattle, WA 98195-7630
(206) 616-9867
Date____________________________NAME______________________________________________________
ADDRESS__________________________________________________ PHONE____________________________________________________ DATE OF BIRTH____________________________________________
Drug, Strength, Quantity
SIG
Substitution permitted.__________________________________ Dispense as written.______________________________________________________
REFILL______________TIMES DEA No. __________________________________________________________________ Prescriber phone___________________________ Prescriber address _______________________________________________________ PHONED BY____________________________________________ RECEIVED BY_____________________________________________________________
Transfer
Original Rx#:Original Date Written:Last Fill Date:Refills Remaining:
Name & Address of Pharmacy
University of WashingtonPharmaceutical Care Learning Center
1959 NE Pacific Street, Room T484Seattle, WA 98195-7630
(206) 616-9867
Date____________________________NAME______________________________________________________
ADDRESS__________________________________________________ PHONE____________________________________________________ DATE OF BIRTH____________________________________________
Drug, Strength, Quantity
SIG
Substitution permitted.__________________________________ Dispense as written.______________________________________________________
REFILL______________TIMES DEA No. __________________________________________________________________ Prescriber phone___________________________ Prescriber address _______________________________________________________ PHONED BY____________________________________________ RECEIVED BY_____________________________________________________________
Transfer
Original Rx#:Original Date Written:Last Fill Date:Refills Remaining:
Name & Address of PharmacyPhone #:
University of WashingtonPharmaceutical Care Learning Center
1959 NE Pacific Street, Room T484Seattle, WA 98195-7630
(206) 616-9867
Date____________________________NAME______________________________________________________
ADDRESS__________________________________________________ PHONE____________________________________________________ DATE OF BIRTH____________________________________________
Drug, Strength, Quantity
SIG
Substitution permitted.__________________________________ Dispense as written.______________________________________________________
REFILL______________TIMES DEA No. __________________________________________________________________ Prescriber phone___________________________ Prescriber address _______________________________________________________ PHONED BY____________________________________________ RECEIVED BY_____________________________________________________________
Transfer
Original Rx#:Original Date Written:Last Fill Date:Refills Remaining:
Name & Address of Pharmacy:Phone #:RPh:
University of WashingtonPharmaceutical Care Learning Center
1959 NE Pacific Street, Room T484Seattle, WA 98195-7630
(206) 616-9867
Date____________________________NAME______________________________________________________
ADDRESS__________________________________________________ PHONE____________________________________________________ DATE OF BIRTH____________________________________________
Drug, Strength, Quantity
SIG
Substitution permitted.__________________________________ Dispense as written.______________________________________________________
REFILL______________TIMES DEA No. __________________________________________________________________ Prescriber phone___________________________ Prescriber address _______________________________________________________ PHONED BY____________________________________________ RECEIVED BY_____________________________________________________________
Transfer
Original Rx#:Original Date Written:Last Fill Date:Refills Remaining:
Name & Address of Pharmacy:Phone #:RPh:Pharmacy DEA #:
University of WashingtonPharmaceutical Care Learning Center
1959 NE Pacific Street, Room T484Seattle, WA 98195-7630
(206) 616-9867
Date____________________________NAME______________________________________________________
ADDRESS__________________________________________________ PHONE____________________________________________________ DATE OF BIRTH____________________________________________
Drug, Strength, Quantity
SIG
Substitution permitted.__________________________________ Dispense as written.______________________________________________________
REFILL______________TIMES DEA No. __________________________________________________________________ Prescriber phone___________________________ Prescriber address _______________________________________________________ PHONED BY____________________________________________ RECEIVED BY_____________________________________________________________
Transfer
Original Rx#:Original Date Written:Last Fill Date:Refills Remaining:
Name & Address of Pharmacy:Phone #:RPh:Pharmacy DEA #:
RBVO
