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

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Presentation on theme: "New & Transfer Rx Dr. Allen Pharm 585 January 4 th 2011."— Presentation transcript:

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

2 New Rx

3 University of Washington Pharmaceutical Care Learning Center 1959 NE Pacific Street, Room T484 Seattle, WA 98195-7630 (206) 616-9867 Date____________________________ Name______________________________________________________ Address____________________________________________________ Phone______________________________________________________ Date of Birth________________________________________________ Substitution permitted.__________________________________ Dispense as written.______________________________________________________ REFILL______________TIMESDEA No. __________________________________________________________________ Prescriber phone___________________________Prescriber address _______________________________________________________ PHONED BY____________________________________________ RECEIVED BY_____________________________________________________________

4 University of Washington Pharmaceutical Care Learning Center 1959 NE Pacific Street, Room T484 Seattle, WA 98195-7630 (206) 616-9867 Date____________________________ Name________________________________ Address____________________________________________________ Phone______________________________________________________ Date of Birth________________________________________________ Substitution permitted.__________________________________ Dispense as written.______________________________________________________ REFILL______________TIMESDEA No. __________________________________________________________________ Prescriber phone___________________________Prescriber address _______________________________________________________ PHONED BY____________________________________________ RECEIVED BY_____________________________________________________________

5 University of Washington Pharmaceutical Care Learning Center 1959 NE Pacific Street, Room T484 Seattle, WA 98195-7630 (206) 616-9867 Date____________________________ Name______________________________________________________ Address____________________________________________________ Phone______________________________________________________ Date of Birth_________________________ Substitution permitted.__________________________________ Dispense as written.______________________________________________________ REFILL______________TIMESDEA No. __________________________________________________________________ Prescriber phone___________________________Prescriber address _______________________________________________________ PHONED BY____________________________________________ RECEIVED BY_____________________________________________________________

6 University of Washington Pharmaceutical Care Learning Center 1959 NE Pacific Street, Room T484 Seattle, WA 98195-7630 (206) 616-9867 Date____________________ Name______________________________________________________ Address____________________________________________________ Phone______________________________________________________ Date of Birth________________________________________________ Substitution permitted.__________________________________ Dispense as written.______________________________________________________ REFILL______________TIMESDEA No. __________________________________________________________________ Prescriber phone___________________________Prescriber address _______________________________________________________ PHONED BY____________________________________________ RECEIVED BY_____________________________________________________________

7 University of Washington Pharmaceutical Care Learning Center 1959 NE Pacific Street, Room T484 Seattle, WA 98195-7630 (206) 616-9867 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_____________________________________________________________

8 University of Washington Pharmaceutical Care Learning Center 1959 NE Pacific Street, Room T484 Seattle, WA 98195-7630 (206) 616-9867 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_____________________________________________________________

9 University of Washington Pharmaceutical Care Learning Center 1959 NE Pacific Street, Room T484 Seattle, WA 98195-7630 (206) 616-9867 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_____________________________________________________________

10 University of Washington Pharmaceutical Care Learning Center 1959 NE Pacific Street, Room T484 Seattle, WA 98195-7630 (206) 616-9867 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_____________________________________________________________

11 University of Washington Pharmaceutical Care Learning Center 1959 NE Pacific Street, Room T484 Seattle, WA 98195-7630 (206) 616-9867 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_____________________________________________________________

12 University of Washington Pharmaceutical Care Learning Center 1959 NE Pacific Street, Room T484 Seattle, WA 98195-7630 (206) 616-9867 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_____________________________________________________________

13 University of Washington Pharmaceutical Care Learning Center 1959 NE Pacific Street, Room T484 Seattle, WA 98195-7630 (206) 616-9867 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_____________________________________________________________

14 University of Washington Pharmaceutical Care Learning Center 1959 NE Pacific Street, Room T484 Seattle, WA 98195-7630 (206) 616-9867 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________________________________________

15 University of Washington Pharmaceutical Care Learning Center 1959 NE Pacific Street, Room T484 Seattle, WA 98195-7630 (206) 616-9867 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________________________________________

16 Transfer Rx

17 University of Washington Pharmaceutical Care Learning Center 1959 NE Pacific Street, Room T484 Seattle, WA 98195-7630 (206) 616-9867 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_____________________________________________________________

18 University of Washington Pharmaceutical Care Learning Center 1959 NE Pacific Street, Room T484 Seattle, WA 98195-7630 (206) 616-9867 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

19 University of Washington Pharmaceutical Care Learning Center 1959 NE Pacific Street, Room T484 Seattle, WA 98195-7630 (206) 616-9867 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#:

20 University of Washington Pharmaceutical Care Learning Center 1959 NE Pacific Street, Room T484 Seattle, WA 98195-7630 (206) 616-9867 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:

21 University of Washington Pharmaceutical Care Learning Center 1959 NE Pacific Street, Room T484 Seattle, WA 98195-7630 (206) 616-9867 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:

22 University of Washington Pharmaceutical Care Learning Center 1959 NE Pacific Street, Room T484 Seattle, WA 98195-7630 (206) 616-9867 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:

23 University of Washington Pharmaceutical Care Learning Center 1959 NE Pacific Street, Room T484 Seattle, WA 98195-7630 (206) 616-9867 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

24 University of Washington Pharmaceutical Care Learning Center 1959 NE Pacific Street, Room T484 Seattle, WA 98195-7630 (206) 616-9867 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 #:

25 University of Washington Pharmaceutical Care Learning Center 1959 NE Pacific Street, Room T484 Seattle, WA 98195-7630 (206) 616-9867 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:

26 University of Washington Pharmaceutical Care Learning Center 1959 NE Pacific Street, Room T484 Seattle, WA 98195-7630 (206) 616-9867 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 #:

27 University of Washington Pharmaceutical Care Learning Center 1959 NE Pacific Street, Room T484 Seattle, WA 98195-7630 (206) 616-9867 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 #:

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