Patient over 65 enrolled in a PHO

Circle one from each line

Y
1
Z

J
3

A
4

(Circle if patient has

High use Health Card)

Pharmacy Use Only

Dr
.H Pain...............................................
Address ........PO Box 472.........................................
..................................................

NZMC Reg No ................... PAN No ...............

NHI
Mr Master Mrs Miss Ms Dr

Item Count

Prescription
Subsidy Card

Name Of Patient

(Circle One)

Pharmacy Stamp

Full residential address of patient

.........................................................................
.........................................................................
.........................................................................
........................
Date of Birth if patient under 13

Rx

Fosamax 70mg tab

mdu
3/12

Rx

Paracetamol 500mg tab

2t q4h prn
3/12

Date

Prescribers Signature

H Pain

21/ 9 / 12
Dispensed By

.......
Handed Out By
. Checked By

Patient over 65 enrolled in a PHO

Circle one from each line

Y
1
Z

J
3

A
4

(Circle if patient has

High use Health Card)

Pharmacy Use Only

Dr
.H Pain...............................................
Address ........PO Box 472.........................................
..................................................

NZMC Reg No ................... PAN No ...............

NHI
Mr Master Mrs Miss Ms Dr

Item Count

Prescription
Subsidy Card

Name Of Patient

(Circle One)

Pharmacy Stamp

Full residential address of patient

.........................................................................
.........................................................................
.........................................................................
........................
Date of Birth if patient under 13

Rx

Rx

Panadeine tab
2t q4h mdu

200

Laxsol tab
12t bd

200

Date

Prescribers Signature

H Pain

21/ 9 / 12
Dispensed By

.......
Handed Out By
. Checked By

Patient over 65 enrolled in a PHO

Circle one from each line

Y
1
Z

J
3

A
4

(Circle if patient has

High use Health Card)

Pharmacy Use Only

Dr
.H Pain...............................................
Address ........PO Box 472.........................................
..................................................

NZMC Reg No ................... PAN No ...............

NHI
Mr Master Mrs Miss Ms Dr

Item Count

Prescription
Subsidy Card

Name Of Patient

(Circle One)

Pharmacy Stamp

Full residential address of patient

.........................................................................
.........................................................................
.........................................................................
........................
Date of Birth if patient under 13

Rx

Rx

Flucloxacillin 250 caps

2 stat 1 tds

7/7

Paracetamol 500mg tab

mdu

100

Date

Prescribers Signature

H Pain

21/ 9 / 12
Dispensed By

.......
Handed Out By
. Checked By

Patient over 65 enrolled in a PHO

Circle one from each line

Y
1
Z

J
3

A
4

(Circle if patient has

High use Health Card)

Pharmacy Use Only

Dr
.H Pain...............................................
Address ........PO Box 472.........................................
..................................................

NZMC Reg No ................... PAN No ...............

NHI
Mr Master Mrs Miss Ms Dr

Item Count

Prescription
Subsidy Card

Name Of Patient

(Circle One)

Pharmacy Stamp

Full residential address of patient

.........................................................................
.........................................................................
.........................................................................
........................
Date of Birth if patient under 13

Rx

Polytears drops
One drop qid in both eyes

Rx

Urea 10% cream

mdu

Date

3/12

500g

Prescribers Signature

H Pain

21/ 9 / 12
Dispensed By

.......
Handed Out By
. Checked By

Patient over 65 enrolled in a PHO

Circle one from each line

Y
1
Z

J
3

A
4

(Circle if patient has

High use Health Card)

Pharmacy Use Only

Dr
.H Pain...............................................
Address ........PO Box 472.........................................
..................................................

NZMC Reg No ................... PAN No ...............

NHI
Mr Master Mrs Miss Ms Dr

Item Count

Prescription
Subsidy Card

Name Of Patient

(Circle One)

Pharmacy Stamp

Full residential address of patient

.........................................................................
.........................................................................
.........................................................................
........................
Date of Birth if patient under 13

Rx

Rx

Calcium Carbonate 500mg tab

2t daily

3/12

Etidronate 200mg
2t daily

2/52

Date

Prescribers Signature

H Pain

21/ 9 / 12
Dispensed By

.......
Handed Out By
. Checked By

Patient over 65 enrolled in a PHO

Circle one from each line

Y
1
Z

J
3

A
4

(Circle if patient has

High use Health Card)

Pharmacy Use Only

Dr
.H Pain...............................................
Address ........PO Box 472.........................................
..................................................

NZMC Reg No ................... PAN No ...............

NHI
Mr Master Mrs Miss Ms Dr

Item Count

Prescription
Subsidy Card

Name Of Patient

(Circle One)

Pharmacy Stamp

Full residential address of patient

.........................................................................
.........................................................................
.........................................................................
........................
Date of Birth if patient under 13

Rx

Temazepam
10-20mg nocte
7/7

Rx

Mucilaginous laxative
mdu

Date

3/12

Prescribers Signature

H Pain

21/ 9 / 12
Dispensed By

.......
Handed Out By
. Checked By