MED CERT Mejia

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DATE RX NO.

RX NO. NAME OF PHYSICIAN NAME OF PATIENT ADDRESS OF PATIENT NAME OF PRODUCT DOSAGE FORM BATCH / LOT EXPIRY DATE QTY(-) REMARKS DISPENSING
PARTIALLY
DISPENSED AND STRENGTH NO. SERVED FILLED (PF) PHARMACIST
FULLY SERVED
GENERIC NAME BRAND NAME (FS)

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