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FLYING SAMARITANS EL HONGO CLINIC
PHARMACY ORDER SHEET
ANTI-HYPERTENSIVES
PHARMACY
BETA-BLOCKERS
INSTRUCTIONS
DISPENSE
NOTES/INITIALS
ACE-INHIBITORS
CA-CHANNEL BLOCKERS
DIURETICS
ANTIBIOTICS
___________ mg capsules Take_______caps_______times a day, for ______days, for_______ Take_______ml(____mg)_______times a day, for ______days, for_______ Take_______tablets_______times a day, for ______days, for_______ Take_______ml(____mg)_______times a day, for ______days, for_______ ___________ mg capsules Take_______caps_______times a day, for ______days, for_______ Take_______ml(____mg)_______times a day, for ______days, for_______ Take_______tablets_______times a day, for ______days, for_______ Take_______tablets_______times a day, for ______days, for_______ Take_______tablets_______times a day, for ______days, for_______ ASTHMA/ALLERGY/COLD
Take________spray to both nostrils_______times a day ______gtts to______eyes ______times a day Take________tablets every_______hrs for_______ Take_______ml(____mg) every_______hrs for_______ Take________tablets every_______hours for congestion Take_______ml(____mg) every_______hours for congestion Put______drops in each nostril_____times a day for congestion ADDITIONAL MEDS, PLEASE SEE ADDITIONAL PAGE: YES NO
If yes, this page ________of ________
PATIENT NAME: _______________________________________________DATE:_______________________
ORDERING PHYSICIAN: ______________________________________________________
PHARMACIST OR TECH NAME:_______________________________PHARMACY STUDENT(S): _____________________
__________________________________________ ALL MED ORDERS ON THIS PAGE HAVE BEEN FILLED: YES NO
FLYING SAMARITANS EL HONGO CLINIC
PHARMACY ORDER SHEET
PHARMACY
DIABETES
INSTRUCTIONS
DISPENSE
NOTES/INITIALS
PAIN/FEVER
Take________tablets every_______hours, for_______ Take________tablets every_______hours, for_______ Take________tablets every_______hours, for_______ Take_______ml(____mg) every______hrs, for_______ Take_______ml(____mg) every______hrs, for_______ Take_______ml(____mg) every______hrs, for_______ MISCELLANEOUS
Take________tablets_______times a day for constipation Take one packet with juice, tea, coffe, water for constipation Apply to affected areas ______times a day Apply to affected areas ______times a day Medication name/dosage
Instructions
Dispense Quantity
Special Instructions
PATIENT NAME: _______________________________________________DATE:_____________________
ORDERING PHYSICIAN: ______________________________________________________
PHARMACIST OR TECH NAME:______________________________PHARMACY STUDENT(S):
___________________________________________________________________________ ALL MED ORDERS ON THIS PAGE HAVE BEEN FILLED: YES NO

Source: http://flyingsamselhongo.com/pharmacyordersheet%20.pdf