Name: Juanita Gomez X Original Entry or Doctor: Dr. Jones Transferred from page __ Greenleaf N569 Pharmacy: Prescription Number: Tramadol 50mg March 3, yr Medication and Strength: Prescription Date: Take 1 tablet by mouth twice daily Directions: Amount Amount Amount Date Time Route Signature on Hand Used Left Dowd Linda White /Sam 3/3/yr 9am Amount left ____ transferred to page ______ Signature ____________________________ Signature ____________________________ 7| Page
Name: Juanita Gomez X Original Entry or Doctor: Dr. Jones Transferred from page __ Pharmacy: Greenleaf Prescription Number: N569 Medication and Strength: Tramadol 50mg Prescription Date: March 3, yr Directions: Take 1 tablet by mouth twice daily Date Time Route Amount on Hand Amount Used Amount Left Signature 3/3/yr 9am Linda White /Sam Dowd Amount left ____ transferred to page ______ Signature ____________________________ Signature ____________________________ 7| Page