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New & Transfer Rx

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 98195- 7630 (206) 616-9867 Date____________________________

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New & Transfer Rx

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  1. New & Transfer Rx Dr. Allen Pharm 585 January 4th 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______________TIMES DEA 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______________TIMES DEA 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______________TIMES DEA 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______________TIMES DEA 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______________TIMES DEA 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______________TIMES DEA 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______________TIMES DEA 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______________TIMES DEA 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______________TIMES DEA 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______________TIMES DEA 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______________TIMES DEA No. __________________________________________________________________ Prescriber phone___________________________ Prescriber address _______________________________________________________ PHONED BY____________________________________________ RECEIVED BY________________________________________ RBVO

  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_____________________________________________________________ RBVO Transfer Original Rx#: Original Date Written: Last Fill Date: Refills Remaining: Name & Address of Pharmacy: Phone #: RPh: Pharmacy DEA #:

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