RECEITUÁRIO CONTROLE ESPECIAL RECEITUÁRIO CONTROLE ESPECIAL

INDENTIFICAÇÃO DO EMITENTE INDENTIFICAÇÃO DO EMITENTE

Nome completo: ______________________________
____________________________________________
CRM:____________________UF_________Nº_______
Endereço completo e telefone:
____________________________________________
Cidade:___________________________UF:________
1ª Via (Farmácia) - 2ª Via (Paciente)
Nome completo: ____________________________
____________________________________________
CRM:____________________UF________Nº______
Endereço completo e telefone:
__________________________________________
SECRETARIA MUNICIPAL DE SAÚDE Cidade:__________________________UF:_______ SECRETARIA MUNICIPAL DE SAÚDE
1ª Via (Farmácia) - 2ª Via (Paciente)

Paciente:________________________________________________________________ Paciente:_______________________________________________________________
Endereço:_______________________________________________________________ Endereço:______________________________________________________________
Prescrição:_______________________________________________________________ Prescrição:______________________________________________________________
___________________________________________________________________________________
____________________________________________________________________________________________
________________________________________________________________________________
__________________________________________________________________________________________
________________________________________________________________________________
__________________________________________________________________________________________
________________________________________________________________________________
__________________________________________________________________________________________
________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
___________________________________________________________________________________
________________________________________________________________________________
__________________________________________________________________________________________
________________________________________________________________________________
__________________________________________________________________________________________
________________________________________________________________________________
__________________________________________________________________________________________
________________________________________________________________________________
__________________________________________________________________________________________
________________________________________________________________________________
__________________________________________________________________________________________
________________________________________________________________________________
__________________________________________________________________________________________
________________________________________________________________________________
__________________________________________________________________________________________
________________________________________________________________________________
__________________________________________________________________________________________
________________________________________________________________________________
__________________________________________________________________________________________
________________________________________________________________________________ _________________________________________________________________________

INDENTIFICAÇÃO DO COMPRADOR INDENTIFICAÇÃO DO FORNECEDOR INDENTIFICAÇÃO DO COMPRADOR INDENTIFICAÇÃO DO FORNECEDOR

Nome:_______________________________________
___________________________________________
Ident:_______________________Órg. Emissor:______
End:_________________________________________
____________________________________________
Cidade:__________________________UF:_________ ___________________
Telefone:_____________________________________ Assinatura do Farmacêutico
Nome:_____________________________________
_________________________________________
__
Ident:_____________________Órg. Emissor:_____
End:_______________________________________
__________________________________________
Cidade:___________________________UF:______ ___________________
Data:___/___/____ Telefone:___________________________________ Assinatura do Farmacêutico Data:___/___/____