New & Transfer Rx Dr. Allen Pharm 585 January 4 th 2011.

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Presentation transcript:

New & Transfer Rx Dr. Allen Pharm 585 January 4 th 2011

New Rx

University of Washington Pharmaceutical Care Learning Center 1959 NE Pacific Street, Room T484 Seattle, WA (206) Date____________________________ Name______________________________________________________ Address____________________________________________________ Phone______________________________________________________ Date of Birth________________________________________________ Substitution permitted.__________________________________ Dispense as written.______________________________________________________ REFILL______________TIMESDEA No. __________________________________________________________________ Prescriber phone___________________________Prescriber address _______________________________________________________ PHONED BY____________________________________________ RECEIVED BY_____________________________________________________________

University of Washington Pharmaceutical Care Learning Center 1959 NE Pacific Street, Room T484 Seattle, WA (206) Date____________________________ Name________________________________ Address____________________________________________________ Phone______________________________________________________ Date of Birth________________________________________________ Substitution permitted.__________________________________ Dispense as written.______________________________________________________ REFILL______________TIMESDEA No. __________________________________________________________________ Prescriber phone___________________________Prescriber address _______________________________________________________ PHONED BY____________________________________________ RECEIVED BY_____________________________________________________________

University of Washington Pharmaceutical Care Learning Center 1959 NE Pacific Street, Room T484 Seattle, WA (206) Date____________________________ Name______________________________________________________ Address____________________________________________________ Phone______________________________________________________ Date of Birth_________________________ Substitution permitted.__________________________________ Dispense as written.______________________________________________________ REFILL______________TIMESDEA No. __________________________________________________________________ Prescriber phone___________________________Prescriber address _______________________________________________________ PHONED BY____________________________________________ RECEIVED BY_____________________________________________________________

University of Washington Pharmaceutical Care Learning Center 1959 NE Pacific Street, Room T484 Seattle, WA (206) Date____________________ Name______________________________________________________ Address____________________________________________________ Phone______________________________________________________ Date of Birth________________________________________________ Substitution permitted.__________________________________ Dispense as written.______________________________________________________ REFILL______________TIMESDEA No. __________________________________________________________________ Prescriber phone___________________________Prescriber address _______________________________________________________ PHONED BY____________________________________________ RECEIVED BY_____________________________________________________________

University of Washington Pharmaceutical Care Learning Center 1959 NE Pacific Street, Room T484 Seattle, WA (206) Date____________________________ Name______________________________________________________ Address____________________________________________________ Phone______________________________________________________ Date of Birth________________________________________________ Drug, Strength, Quantity Substitution permitted.__________________________________ Dispense as written.______________________________________________________ REFILL______________TIMESDEA No. __________________________________________________________________ Prescriber phone___________________________Prescriber address _______________________________________________________ PHONED BY____________________________________________ RECEIVED BY_____________________________________________________________

University of Washington Pharmaceutical Care Learning Center 1959 NE Pacific Street, Room T484 Seattle, WA (206) Date____________________________ Name______________________________________________________ Address____________________________________________________ Phone______________________________________________________ Date of Birth________________________________________________ Drug, Strength, Quantity SIG Substitution permitted.__________________________________ Dispense as written.______________________________________________________ REFILL______________TIMESDEA No. __________________________________________________________________ Prescriber phone___________________________Prescriber address _______________________________________________________ PHONED BY____________________________________________ RECEIVED BY_____________________________________________________________

University of Washington Pharmaceutical Care Learning Center 1959 NE Pacific Street, Room T484 Seattle, WA (206) Date____________________________ Name______________________________________________________ Address____________________________________________________ Phone______________________________________________________ Date of Birth________________________________________________ Drug, Strength, Quantity SIG Substitution permitted.__________________ Dispense as written.________________ REFILL______________TIMESDEA No. __________________________________________________________________ Prescriber phone___________________________Prescriber address _______________________________________________________ PHONED BY____________________________________________ RECEIVED BY_____________________________________________________________

University of Washington Pharmaceutical Care Learning Center 1959 NE Pacific Street, Room T484 Seattle, WA (206) Date____________________________ Name______________________________________________________ Address____________________________________________________ Phone______________________________________________________ Date of Birth________________________________________________ Drug, Strength, Quantity SIG Substitution permitted.__________________________________ Dispense as written.______________________________________________________ REFILL______________TIMES DEA No. __________________________________________________________________ Prescriber phone___________________________Prescriber address _______________________________________________________ PHONED BY____________________________________________ RECEIVED BY_____________________________________________________________

University of Washington Pharmaceutical Care Learning Center 1959 NE Pacific Street, Room T484 Seattle, WA (206) Date____________________________ Name______________________________________________________ Address____________________________________________________ Phone______________________________________________________ Date of Birth________________________________________________ Drug, Strength, Quantity SIG Substitution permitted.__________________________________ Dispense as written.______________________________________________________ REFILL______________TIMES DEA No. ________________________________ Prescriber phone___________________________Prescriber address _______________________________________________________ PHONED BY____________________________________________ RECEIVED BY_____________________________________________________________

University of Washington Pharmaceutical Care Learning Center 1959 NE Pacific Street, Room T484 Seattle, WA (206) Date____________________________ Name______________________________________________________ Address____________________________________________________ Phone______________________________________________________ Date of Birth________________________________________________ Drug, Strength, Quantity SIG Substitution permitted.__________________________________ Dispense as written.______________________________________________________ REFILL______________TIMESDEA No. __________________________________________________________________ Prescriber phone________________ Prescriber address _______________________________________________________ PHONED BY____________________________________________ RECEIVED BY_____________________________________________________________

University of Washington Pharmaceutical Care Learning Center 1959 NE Pacific Street, Room T484 Seattle, WA (206) Date____________________________ Name______________________________________________________ Address____________________________________________________ Phone______________________________________________________ Date of Birth________________________________________________ Drug, Strength, Quantity SIG Substitution permitted.__________________________________ Dispense as written.______________________________________________________ REFILL______________TIMESDEA No. __________________________________________________________________ Prescriber phone___________________________Prescriber address _______________________________________________________ PHONED BY____________________________ RECEIVED BY_____________________________________________________________

University of Washington Pharmaceutical Care Learning Center 1959 NE Pacific Street, Room T484 Seattle, WA (206) Date____________________________ Name______________________________________________________ Address____________________________________________________ Phone______________________________________________________ Date of Birth________________________________________________ Drug, Strength, Quantity SIG Substitution permitted.__________________________________ Dispense as written.______________________________________________________ REFILL______________TIMESDEA No. __________________________________________________________________ Prescriber phone___________________________Prescriber address _______________________________________________________ PHONED BY____________________________________________ RECEIVED BY________________________________________

University of Washington Pharmaceutical Care Learning Center 1959 NE Pacific Street, Room T484 Seattle, WA (206) Date____________________________ Name______________________________________________________ Address____________________________________________________ Phone______________________________________________________ Date of Birth________________________________________________ Drug, Strength, Quantity SIG Substitution permitted.__________________________________ Dispense as written.______________________________________________________ REFILL______________TIMESDEA No. __________________________________________________________________ Prescriber phone___________________________Prescriber address _______________________________________________________ PHONED BY____________________________________________ RECEIVED BY________________________________________

Transfer Rx

University of Washington Pharmaceutical Care Learning Center 1959 NE Pacific Street, Room T484 Seattle, WA (206) Date____________________________ NAME______________________________________________________ ADDRESS__________________________________________________ PHONE____________________________________________________ DATE OF BIRTH____________________________________________ Drug, Strength, Quantity SIG Substitution permitted.__________________________________ Dispense as written.______________________________________________________ REFILL______________TIMESDEA No. __________________________________________________________________ Prescriber phone___________________________Prescriber address _______________________________________________________ PHONED BY____________________________________________ RECEIVED BY_____________________________________________________________

University of Washington Pharmaceutical Care Learning Center 1959 NE Pacific Street, Room T484 Seattle, WA (206) Date____________________________ NAME______________________________________________________ ADDRESS__________________________________________________ PHONE____________________________________________________ DATE OF BIRTH____________________________________________ Drug, Strength, Quantity SIG Substitution permitted.__________________________________ Dispense as written.______________________________________________________ REFILL______________TIMESDEA No. __________________________________________________________________ Prescriber phone___________________________Prescriber address _______________________________________________________ PHONED BY____________________________________________ RECEIVED BY_____________________________________________________________ Transfer

University of Washington Pharmaceutical Care Learning Center 1959 NE Pacific Street, Room T484 Seattle, WA (206) Date____________________________ NAME______________________________________________________ ADDRESS__________________________________________________ PHONE____________________________________________________ DATE OF BIRTH____________________________________________ Drug, Strength, Quantity SIG Substitution permitted.__________________________________ Dispense as written.______________________________________________________ REFILL______________TIMESDEA No. __________________________________________________________________ Prescriber phone___________________________Prescriber address _______________________________________________________ PHONED BY____________________________________________ RECEIVED BY_____________________________________________________________ Transfer Original Rx#:

University of Washington Pharmaceutical Care Learning Center 1959 NE Pacific Street, Room T484 Seattle, WA (206) Date____________________________ NAME______________________________________________________ ADDRESS__________________________________________________ PHONE____________________________________________________ DATE OF BIRTH____________________________________________ Drug, Strength, Quantity SIG Substitution permitted.__________________________________ Dispense as written.______________________________________________________ REFILL______________TIMESDEA No. __________________________________________________________________ Prescriber phone___________________________Prescriber address _______________________________________________________ PHONED BY____________________________________________ RECEIVED BY_____________________________________________________________ Transfer Original Rx#: Original Date Written:

University of Washington Pharmaceutical Care Learning Center 1959 NE Pacific Street, Room T484 Seattle, WA (206) Date____________________________ NAME______________________________________________________ ADDRESS__________________________________________________ PHONE____________________________________________________ DATE OF BIRTH____________________________________________ Drug, Strength, Quantity SIG Substitution permitted.__________________________________ Dispense as written.______________________________________________________ REFILL______________TIMESDEA No. __________________________________________________________________ Prescriber phone___________________________Prescriber address _______________________________________________________ PHONED BY____________________________________________ RECEIVED BY_____________________________________________________________ Transfer Original Rx#: Original Date Written: Last Fill Date:

University of Washington Pharmaceutical Care Learning Center 1959 NE Pacific Street, Room T484 Seattle, WA (206) Date____________________________ NAME______________________________________________________ ADDRESS__________________________________________________ PHONE____________________________________________________ DATE OF BIRTH____________________________________________ Drug, Strength, Quantity SIG Substitution permitted.__________________________________ Dispense as written.______________________________________________________ REFILL______________TIMESDEA No. __________________________________________________________________ Prescriber phone___________________________Prescriber address _______________________________________________________ PHONED BY____________________________________________ RECEIVED BY_____________________________________________________________ Transfer Original Rx#: Original Date Written: Last Fill Date: Refills Remaining:

University of Washington Pharmaceutical Care Learning Center 1959 NE Pacific Street, Room T484 Seattle, WA (206) Date____________________________ NAME______________________________________________________ ADDRESS__________________________________________________ PHONE____________________________________________________ DATE OF BIRTH____________________________________________ Drug, Strength, Quantity SIG Substitution permitted.__________________________________ Dispense as written.______________________________________________________ REFILL______________TIMESDEA No. __________________________________________________________________ Prescriber phone___________________________Prescriber address _______________________________________________________ PHONED BY____________________________________________ RECEIVED BY_____________________________________________________________ Transfer Original Rx#: Original Date Written: Last Fill Date: Refills Remaining: Name & Address of Pharmacy

University of Washington Pharmaceutical Care Learning Center 1959 NE Pacific Street, Room T484 Seattle, WA (206) Date____________________________ NAME______________________________________________________ ADDRESS__________________________________________________ PHONE____________________________________________________ DATE OF BIRTH____________________________________________ Drug, Strength, Quantity SIG Substitution permitted.__________________________________ Dispense as written.______________________________________________________ REFILL______________TIMESDEA No. __________________________________________________________________ Prescriber phone___________________________Prescriber address _______________________________________________________ PHONED BY____________________________________________ RECEIVED BY_____________________________________________________________ Transfer Original Rx#: Original Date Written: Last Fill Date: Refills Remaining: Name & Address of Pharmacy Phone #:

University of Washington Pharmaceutical Care Learning Center 1959 NE Pacific Street, Room T484 Seattle, WA (206) Date____________________________ NAME______________________________________________________ ADDRESS__________________________________________________ PHONE____________________________________________________ DATE OF BIRTH____________________________________________ Drug, Strength, Quantity SIG Substitution permitted.__________________________________ Dispense as written.______________________________________________________ REFILL______________TIMESDEA No. __________________________________________________________________ Prescriber phone___________________________Prescriber address _______________________________________________________ PHONED BY____________________________________________ RECEIVED BY_____________________________________________________________ Transfer Original Rx#: Original Date Written: Last Fill Date: Refills Remaining: Name & Address of Pharmacy: Phone #: RPh:

University of Washington Pharmaceutical Care Learning Center 1959 NE Pacific Street, Room T484 Seattle, WA (206) Date____________________________ NAME______________________________________________________ ADDRESS__________________________________________________ PHONE____________________________________________________ DATE OF BIRTH____________________________________________ Drug, Strength, Quantity SIG Substitution permitted.__________________________________ Dispense as written.______________________________________________________ REFILL______________TIMESDEA No. __________________________________________________________________ Prescriber phone___________________________Prescriber address _______________________________________________________ PHONED BY____________________________________________ RECEIVED BY_____________________________________________________________ Transfer Original Rx#: Original Date Written: Last Fill Date: Refills Remaining: Name & Address of Pharmacy: Phone #: RPh: Pharmacy DEA #:

University of Washington Pharmaceutical Care Learning Center 1959 NE Pacific Street, Room T484 Seattle, WA (206) Date____________________________ NAME______________________________________________________ ADDRESS__________________________________________________ PHONE____________________________________________________ DATE OF BIRTH____________________________________________ Drug, Strength, Quantity SIG Substitution permitted.__________________________________ Dispense as written.______________________________________________________ REFILL______________TIMESDEA No. __________________________________________________________________ Prescriber phone___________________________Prescriber address _______________________________________________________ PHONED BY____________________________________________ RECEIVED BY_____________________________________________________________ Transfer Original Rx#: Original Date Written: Last Fill Date: Refills Remaining: Name & Address of Pharmacy: Phone #: RPh: Pharmacy DEA #: