Prescription Example (Written)

Name of Patient: __________________________ Date: _________

Address of Pharmacy: _____________________ DOB: __________

Rx

Chlorhexidine Gluconate 0.12%

Dispense 3 Bottles
Sig: Swish and spit 15 mL p.o b.i.d after toothbrushing for infection until gone

 Dispense as written

# refills

Signature: ____________________

Name of Patient: __________________________ Date: _________

Address of Pharmacy: _____________________ DOB: __________

Rx:

Ibuprofen 800 mg
Dispense 21 tablets
Sig: Take one tablet by mouth q8h prn for pain. Max 3 tablets/day. Take with food.

 Dispense as written

# refills

Signature: ____________________

*** Dispense as written means other name brands will not be used, i.e. Motrin brand used
but not Advil***