ROSE PHARMACY, INC.
Barangay Taft,Espina Extension, Surigao City
Date:________________
Patient Name: __________________________________
Address: ______________________________________
Generic Name: _________________________________
Brand Name: __________________________________
Strength: ______________________________________
Quantity Prescribed:_______________ _____________
Quantity Served: ____________ Balance: ___________
Lot Number: _______________ Expiry: _____________
\
Signa: _______________________________________
Physician: ____________________________________
License Num: _______________ PTR: ______________
Address: _____________________________________
\
Pharmacist: ___________________________________
License Num: _________________________________
ROSE PHARMACY, INC.
\
Barangay Taft,Espina Extension, Surigao City
Date:________________
Patient Name: __________________________________
Address: ______________________________________
Generic Name: _________________________________
Brand Name:
\ __________________________________
Strength: ______________________________________
Quantity Prescribed:_______________ _____________
Quantity Served: ____________ Balance: ___________
Lot Number: _______________ Expiry: _____________
Signa: _______________________________________
Physician:
\ ____________________________________
License Num: _______________ PTR: ______________
Address: _____________________________________
Pharmacist: ___________________________________
License Num: _________________________________
ROSE PHARMACY, INC.
Barangay Taft,Espina Extension, Surigao City
Date:________________
Patient Name: __________________________________
Address: ______________________________________
Generic Name: _________________________________
Brand Name: __________________________________
Strength: ______________________________________
Quantity Prescribed:_______________ _____________
Quantity Served: ____________ Balance: ___________
Lot Number: _______________ Expiry: _____________
Signa: _______________________________________
Physician: ____________________________________
License Num: _______________ PTR: ______________
Address: _____________________________________
Pharmacist: ___________________________________
License Num: _________________________________
ROSE PHARMACY, INC.
Barangay Taft,Espina Extension, Surigao City
Date:________________
Patient Name: __________________________________
Address: ______________________________________
Generic Name: _________________________________
Brand Name: __________________________________
Strength: ______________________________________
Quantity Prescribed:_______________ _____________
Quantity Served: ____________ Balance: ___________
Lot Number: _______________ Expiry: _____________
Signa: _______________________________________
Physician: ____________________________________
License Num: _______________ PTR: ______________
Address: _____________________________________
Pharmacist: ___________________________________
License Num: _________________________________
ROSE PHARMACY, INC.
Barangay Taft,Espina Extension, Surigao City
Date:________________
Patient Name: __________________________________
Address: ______________________________________
Generic Name: _________________________________
Brand Name: __________________________________
Strength: ______________________________________
Quantity Prescribed:_______________ _____________
Quantity Served: ____________ Balance: ___________
Lot Number: _______________ Expiry: _____________
Signa: _______________________________________
Physician: ____________________________________
License Num: _______________ PTR: ______________
Address: _____________________________________
Pharmacist: ___________________________________
License Num: _________________________________
ROSE PHARMACY, INC.
Barangay Taft,Espina Extension, Surigao City
Date:________________
Patient Name: __________________________________
Address: ______________________________________
Generic Name: _________________________________
Brand Name: __________________________________
Strength: ______________________________________
Quantity Prescribed:_______________ _____________
Quantity Served: ____________ Balance: ___________
Lot Number: _______________ Expiry: _____________
Signa: _______________________________________
Physician: ____________________________________
License Num: _______________ PTR: ______________
Address: _____________________________________
Pharmacist: ___________________________________
License Num: _________________________________