MARITIME HOSPITALS TRUST

OUTPATIENT PRESCRIPTION FORM

For Teaching Purposes Only
A MAXIMUM SUPPLY OF FOUR WEEKS WILL NORMALLY BE ISSUED

Patient Details

Prescription Stamps

Surname:
Mr/Mrs/Ms Master Picks
Address:
2 The High Street
Newtown
071029MP

Case No:

PRIVATE

Age: 3
Weight: 12.8kg
(PLEASE USE BLOCK LETTERS)

Medicines
Required:

TRUST

PHARMACY
Amount Issued

Bonjela (sugar free) for mouth lesions

Apply up to every three hours x 1
Hydrocortisone 0.1% cream
Apply sparingly to rash on face
Twice daily
X1
Paracetamol suspension
240mg four times a day

No. of
presc. items.

Dispensed
by:

x 1/52

Checked
by:

Date:

Doctors Signature

Consultant

29.10.10

T. Rebora

Raval
Paediatric OPD