                                                                        ZION HOSPITALS

                                                       & Research Centre Pvt. Ltd.

                                            83/1, 2nd Cross Road, Off, Kammanahalli Main Road, Behind Doctors Diagnostic Center,
                                                            Keerthi Layout, Kammanahalli, Bengaluru, Karnataka 560084.
                                            E-mail : info@zionhospitals.com Web : www.zionhospitals.com Ph. : 080 - 43518000

                                                  PRESCRIPTION FORM


                                                                                                                                        23/11/201
                                                                                                                        Date : ......
 IP / OP
                                    Mr                 Balaji

 Name of Patient :


 UHID No. :                                                                      Age / Sex :


 History :
                                                Clo chet heavier




                                                  é nanta. È pair 1/ 1 00



                                                                                                              - 105 days

                                               Headache occa




                                                                     e Sidder
 Diagnosis :

                              BD-150/100 ml/




Drug allergy


                                                                                                         Oral/                Time &
 No.                          Medicine Name                                          Dosage           Parental/                                     Duration
                                                                                                                           Frequency
                                                                                                       Topical

               Cap Somtraz1
                                                                                     1-00 × 10 day!


                                                  40
                  Tal Sompraz 40 007 x 15days



                     Val Leemide 25 ter ×7 days


                       Gaviscon sell 2kg afer meal



                   Tas Metosantan 40/25 1-0-0×1mth




       KTal Sompraz 20 1-01 × 20 days




Name / KMC No. of Doctor                                                                                          & Declank

{'clinic_pharmacy_details': {'clinic_pharmacy_name': 'ZION HOSPITALS & Research Centre Pvt. Ltd.', 'clinic_pharmacy_address': '83/1, 2nd Cross Road, Off, Kammanahalli Main Road, Behind Doctors Diagnostic Center, Keerthi Layout, Kammanahalli, Bengaluru, Karnataka 560084.', 'clinic_pharmacy_city': 'Bengaluru', 'clinic_pharmacy_pincode': '560084'}, 'doctor_details': {'doctor_name': 'Dr. Unknown', 'doctor_qualifications': 'Unknown', 'doctor_registration_number': 'Unknown'}, 'patient_details': {'patient_name': 'Mr. Balaji'}, 'prescription_details': {'date_of_doctor_consultation': '23/11/201'}, 'procedure': {'chief_complaints_diagnosis': 'Headache'}, 'medicine_details': [{'medicine_name': 'Cap Somtraz 1', 'medicine_dosage': '1-0-0', 'medicine_frequency': '10 days', 'course_duration': '10 days'}, {'medicine_name': 'Tab Sompraz 40', 'medicine_dosage': '1-0-1', 'medicine_frequency': '15 days', 'course_duration': '15 days'}, {'medicine_name': 'Val Leemide 25', 'medicine_dosage': '1-0-1', 'medicine_frequency': '7 days', 'course_duration': '7 days'}, {'medicine_name': 'Gaviscon', 'medicine_dosage': '2kg', 'medicine_frequency': 'after meal', 'course_duration': 'unknown'}, {'medicine_name': 'Tas Metosantan 40/25', 'medicine_dosage': '1-0-0', 'medicine_frequency': '1 month', 'course_duration': '1 month'}, {'medicine_name': 'Tab Sompraz 20', 'medicine_dosage': '1-0-1', 'medicine_frequency': '20 days', 'course_duration': '20 days'}], 'lab_test_details': {'lab_test_names': 'NA', 'procedure_request': 'NA'}}