UST

DISPENSING AND MEDICATION COUNSELING)

UST Pharmacy
Date: Compounding Record Prescription no.:

Pharmacist's Name
Patient's Name:
Prescriber's Name

Patient's Address
Prescriber's
Address

Compounded Name: Strength:

Dosage Form:
Master Formula Source:
Total Quantity:
Beyond Use Date:
Ingredients (w/ original amt.) Lot # Expiry Amount Therapeutic Use
Date Used

Compounding Procedures (noteincompatibilities and remedies done to correctit)

Calculations: LabelDirections

Calculated by:
at the back.
Write additional calculations Verified by: