PRESCRIPTION PAD PRESCRIPTION PAD

Name: Age Sex Name: Age Sex

Address: Hospital No. Address: Hospital No.

Rx Date: ___________________ Rx Date: ___________________

Rillus tablet Rillus tablet

# ____ # ____

Sign: 1 tablet ________ a day for ___ weeks Sign: 1 tablet ________ a day for ___ weeks

_______________________M. D _______________________M. D
License No. __________________ License No. __________________
S2. No: _____________________ S2. No: _____________________

PRESCRIPTION PAD PRESCRIPTION PAD

Name: Age Sex Name: Age Sex

Address: Hospital No. Address: Hospital No.

Rx Date: ___________________ Rx Date: ___________________

Rillus tablet Rillus tablet

# ____ # ____

Sign: 1 tablet ________ a day for ___ weeks Sign: 1 tablet ________ a day for ___ weeks

_______________________M. D _______________________M. D
License No. __________________ License No. __________________
S2. No: _____________________ S2. No: _____________________