Podiatry-Board-Prescription Pad Template PDF

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Summary

This is a template for prescribing a medication for a patient (sample)...

Description

Podiatry Board of Australia – prescription template P R E S C R IP TION Full name Qual i fi cati ons : Ins ert P rofes s i on: e.g. podi atri s t or podi atric s urgeon endorsed for s c hedul ed medi c i nes Podiatry Board of Australia - Registration No: Insert Practice Address: Insert Phone: Insert

Patient details: Full name: DOB: Address: Date:

__________________ Prescriber’s signature No subsidy available under the PBS for medicines prescribed by a podiatrist or podiatric surgeon with endorsement for scheduled medicines ____________________________________________________________________________________ Patient Receipt THIS AREA DOES NOT NEED TO BE COMPLETED Patient or agents signature___________________________________________________ Agent address

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