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SAVEMED PHARMACY Tel. #(02)8808-9887 SAVEMED PHARMACY Tel.

#(02)8808-9887
San Antonio, Parañ aque City Physician:____________________ San Antonio, Parañ aque City Physician:____________________
Patient Name:________________________________DATE: ______________________ Patient Name:________________________________DATE: ______________________

Generic Name : _______________________ PA/Pharmacist:______________ Generic Name : _______________________ PA/Pharmacist:______________


Brand Name : _______________________ Brand Name : _______________________
Strength : _______________________ Strength : _______________________
Instruction for Administration: Instruction for Administration:
_____________________________________ Expiration Date: _______________ _____________________________________ Expiration Date: _______________
_____________________________________ Lot#: ____________________________ _____________________________________ Lot#: ____________________________

SAVEMED PHARMACY Tel. #(02)8808-9887 SAVEMED PHARMACY Tel. #(02)8808-9887


San Antonio, Parañ aque City Physician:____________________ San Antonio, Parañ aque City Physician:____________________
Patient Name:________________________________DATE: ______________________ Patient Name:________________________________DATE: ______________________

Generic Name : _______________________ PA/Pharmacist:______________ Generic Name : _______________________ PA/Pharmacist:______________


Brand Name : _______________________ Brand Name : _______________________
Strength : _______________________ Strength : _______________________
Instruction for Administration: Instruction for Administration:
_____________________________________ Expiration Date: _______________ _____________________________________ Expiration Date: _______________
_____________________________________ Lot#: ____________________________ _____________________________________ Lot#: ____________________________

SAVEMED PHARMACY Tel. #(02)8808-9887 SAVEMED PHARMACY Tel. #(02)8808-9887


San Antonio, Parañ aque City Physician:____________________ San Antonio, Parañ aque City Physician:____________________
Patient Name:________________________________DATE: ______________________ Patient Name:________________________________DATE: ______________________

Generic Name : _______________________ PA/Pharmacist:______________ Generic Name : _______________________ PA/Pharmacist:______________


Brand Name : _______________________ Brand Name : _______________________
Strength : _______________________ Strength : _______________________
Instruction for Administration: Instruction for Administration:
_____________________________________ Expiration Date: _______________ _____________________________________ Expiration Date: _______________
_____________________________________ Lot#: ____________________________ _____________________________________ Lot#: ____________________________

SAVEMED PHARMACY Tel. #(02)8808-9887 SAVEMED PHARMACY Tel. #(02)8808-9887


San Antonio, Parañ aque City Physician:____________________ San Antonio, Parañ aque City Physician:____________________
Patient Name:________________________________DATE: ______________________ Patient Name:________________________________DATE: ______________________

Generic Name : _______________________ PA/Pharmacist:______________ Generic Name : _______________________ PA/Pharmacist:______________


Brand Name : _______________________ Brand Name : _______________________
Strength : _______________________ Strength : _______________________
Instruction for Administration: Instruction for Administration:
_____________________________________ Expiration Date: _______________ _____________________________________ Expiration Date: _______________
_____________________________________ Lot#: ____________________________ _____________________________________ Lot#: ____________________________

SAVEMED PHARMACY Tel. #(02)8808-9887 SAVEMED PHARMACY Tel. #(02)8808-9887


San Antonio, Parañ aque City Physician:____________________ San Antonio, Parañ aque City Physician:____________________
Patient Name:________________________________DATE: ______________________ Patient Name:________________________________DATE: ______________________

Generic Name : _______________________ PA/Pharmacist:______________ Generic Name : _______________________ PA/Pharmacist:______________


Brand Name : _______________________ Brand Name : _______________________
Strength : _______________________ Strength : _______________________
Instruction for Administration: Instruction for Administration:
_____________________________________ Expiration Date: _______________ _____________________________________ Expiration Date: _______________
_____________________________________ Lot#: ____________________________ _____________________________________ Lot#: ____________________________

SAVEMED PHARMACY Tel. #(02)8808-9887 SAVEMED PHARMACY Tel. #(02)8808-9887


San Antonio, Parañ aque City Physician:____________________ San Antonio, Parañ aque City Physician:____________________
Patient Name:________________________________DATE: ______________________ Patient Name:________________________________DATE: ______________________

Generic Name : _______________________ PA/Pharmacist:______________ Generic Name : _______________________ PA/Pharmacist:______________


Brand Name : _______________________ Brand Name : _______________________
Strength : _______________________ Strength : _______________________
Instruction for Administration: Instruction for Administration:
_____________________________________ Expiration Date: _______________ _____________________________________ Expiration Date: _______________
_____________________________________ Lot#: ____________________________ _____________________________________ Lot#: ____________________________

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