Please fill out this form to generate your prescription and submit to the pharmacy.
Patient Full Name
*
Mr.
Mrs.
Miss
Dr.
Prof.
Prefix
First Name
Last Name
Patient Identity Number (ID)
Gender
Male
Female
Other
Date of Birth
*
-
Month
-
Day
Year
Date
Patient Age
Mode of Payment
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Cash Payment
Medical Aid Payment
LOYALAID PAY
Select Your Medical Aid
Please Select
LOYALAID DIGITAL PAY
METROPOLITAN MEDICAL AID
LIBERTY MEDICAL AID
DISCOVERY MEDICAL AID
VITALITY MEDICAL AID
MOMENTUM
FEDHEALTH MEDICAL AID
GEMS MEDICAL AID
MEDSHIELD MEDICAL AID
BANKMED MEDICAL AID
BONITAS MEDICAL AID BON0979511
ENGEN MEDICAL AID
Membership Status
Main Member
Dependant
Medical Aid Number
Blood Pressure
blanks
mmHg
Pulse Rate
blank
bpm
RBS
%
Resp Patten
Type a label
Spo2
Blank
%
Temp
Celcius
Diagnosis
Prescription
Prescription Items Rx
Rx Quantity
Rx Frequency (OD/BD/TDS)
Rx Instruction
Rx Duration
1
5ml Teaspoon
10ml
15ml
20ml
1 Tablet
2 Tablets
3Tablets
4 Tablets
5 Tablets
6 Tablets
7 Tablets
8 Tablets
9 Tablets
10 Tablets
11 Tablets
12 Tablets
13 Tablets
14 Tablets
15 Tablets
16 Tablets
17 Tablets
18 Tablets
19 Tablets
20 Tablets
21 Tablets
22 Tablets
23 Tablets
24 Tablets
25 Tablets
26 Tablets
27 Tablets
28 Tablets
29 Tablets
30 Tablets
31 Tablets
32 Tablets
33 Tablets
34 Tablets
35 Tablets
36 Tablets
37 Tablets
38 Tablets
39 Tablets
40 Tablets
Once a day
Immediately
At night
At bedtime
Twice a day
Three times a day
Four times a day
Every four hours
Every six hours
Every eight hours
Every twelve hours
Every twenty-four hours
Once a week
Every week
Once a month
When required
Finish the Course
Only if necessary
Before meals
After meals
With food
On alternate days
At night only
As directed by your healthcare provider
Up to the maximum prescribed dose
Gradually increase or decrease the dose as instructed
1 Day Treatment
2 Days Treatment
3 Days Treatment
4 Days Treatment
5 Days Treatment
6 Days Treatment
7 Days Treatment
1 Week Treatment
2 Weeks Treatment
3 Weeks Treatment
4 Weeks Treatment
5 Weeks Treatment
1 Month Treatment
2 Months Treatment
3 Months Treatment
4 Months Treatment
5 Months Treatment
6 Months Treatment
12 Months Treatment
2
5ml Teaspoon
10ml
15ml
20ml
1 Tablet
2 Tablets
3Tablets
4 Tablets
5 Tablets
6 Tablets
7 Tablets
8 Tablets
9 Tablets
10 Tablets
11 Tablets
12 Tablets
13 Tablets
14 Tablets
15 Tablets
16 Tablets
17 Tablets
18 Tablets
19 Tablets
20 Tablets
21 Tablets
22 Tablets
23 Tablets
24 Tablets
25 Tablets
26 Tablets
27 Tablets
28 Tablets
29 Tablets
30 Tablets
31 Tablets
32 Tablets
33 Tablets
34 Tablets
35 Tablets
36 Tablets
37 Tablets
38 Tablets
39 Tablets
40 Tablets
Once a day
Immediately
At night
At bedtime
Twice a day
Three times a day
Four times a day
Every four hours
Every six hours
Every eight hours
Every twelve hours
Every twenty-four hours
Once a week
Every week
Once a month
When required
Finish the Course
Only if necessary
Before meals
After meals
With food
On alternate days
At night only
As directed by your healthcare provider
Up to the maximum prescribed dose
Gradually increase or decrease the dose as instructed
1 Day Treatment
2 Days Treatment
3 Days Treatment
4 Days Treatment
5 Days Treatment
6 Days Treatment
7 Days Treatment
1 Week Treatment
2 Weeks Treatment
3 Weeks Treatment
4 Weeks Treatment
5 Weeks Treatment
1 Month Treatment
2 Months Treatment
3 Months Treatment
4 Months Treatment
5 Months Treatment
6 Months Treatment
12 Months Treatment
3
5ml Teaspoon
10ml
15ml
20ml
1 Tablet
2 Tablets
3Tablets
4 Tablets
5 Tablets
6 Tablets
7 Tablets
8 Tablets
9 Tablets
10 Tablets
11 Tablets
12 Tablets
13 Tablets
14 Tablets
15 Tablets
16 Tablets
17 Tablets
18 Tablets
19 Tablets
20 Tablets
21 Tablets
22 Tablets
23 Tablets
24 Tablets
25 Tablets
26 Tablets
27 Tablets
28 Tablets
29 Tablets
30 Tablets
31 Tablets
32 Tablets
33 Tablets
34 Tablets
35 Tablets
36 Tablets
37 Tablets
38 Tablets
39 Tablets
40 Tablets
Once a day
Immediately
At night
At bedtime
Twice a day
Three times a day
Four times a day
Every four hours
Every six hours
Every eight hours
Every twelve hours
Every twenty-four hours
Once a week
Every week
Once a month
When required
Finish the Course
Only if necessary
Before meals
After meals
With food
On alternate days
At night only
As directed by your healthcare provider
Up to the maximum prescribed dose
Gradually increase or decrease the dose as instructed
1 Day Treatment
2 Days Treatment
3 Days Treatment
4 Days Treatment
5 Days Treatment
6 Days Treatment
7 Days Treatment
1 Week Treatment
2 Weeks Treatment
3 Weeks Treatment
4 Weeks Treatment
5 Weeks Treatment
1 Month Treatment
2 Months Treatment
3 Months Treatment
4 Months Treatment
5 Months Treatment
6 Months Treatment
12 Months Treatment
4
5ml Teaspoon
10ml
15ml
20ml
1 Tablet
2 Tablets
3Tablets
4 Tablets
5 Tablets
6 Tablets
7 Tablets
8 Tablets
9 Tablets
10 Tablets
11 Tablets
12 Tablets
13 Tablets
14 Tablets
15 Tablets
16 Tablets
17 Tablets
18 Tablets
19 Tablets
20 Tablets
21 Tablets
22 Tablets
23 Tablets
24 Tablets
25 Tablets
26 Tablets
27 Tablets
28 Tablets
29 Tablets
30 Tablets
31 Tablets
32 Tablets
33 Tablets
34 Tablets
35 Tablets
36 Tablets
37 Tablets
38 Tablets
39 Tablets
40 Tablets
Once a day
Immediately
At night
At bedtime
Twice a day
Three times a day
Four times a day
Every four hours
Every six hours
Every eight hours
Every twelve hours
Every twenty-four hours
Once a week
Every week
Once a month
When required
Finish the Course
Only if necessary
Before meals
After meals
With food
On alternate days
At night only
As directed by your healthcare provider
Up to the maximum prescribed dose
Gradually increase or decrease the dose as instructed
1 Day Treatment
2 Days Treatment
3 Days Treatment
4 Days Treatment
5 Days Treatment
6 Days Treatment
7 Days Treatment
1 Week Treatment
2 Weeks Treatment
3 Weeks Treatment
4 Weeks Treatment
5 Weeks Treatment
1 Month Treatment
2 Months Treatment
3 Months Treatment
4 Months Treatment
5 Months Treatment
6 Months Treatment
12 Months Treatment
5
5ml Teaspoon
10ml
15ml
20ml
1 Tablet
2 Tablets
3Tablets
4 Tablets
5 Tablets
6 Tablets
7 Tablets
8 Tablets
9 Tablets
10 Tablets
11 Tablets
12 Tablets
13 Tablets
14 Tablets
15 Tablets
16 Tablets
17 Tablets
18 Tablets
19 Tablets
20 Tablets
21 Tablets
22 Tablets
23 Tablets
24 Tablets
25 Tablets
26 Tablets
27 Tablets
28 Tablets
29 Tablets
30 Tablets
31 Tablets
32 Tablets
33 Tablets
34 Tablets
35 Tablets
36 Tablets
37 Tablets
38 Tablets
39 Tablets
40 Tablets
Once a day
Immediately
At night
At bedtime
Twice a day
Three times a day
Four times a day
Every four hours
Every six hours
Every eight hours
Every twelve hours
Every twenty-four hours
Once a week
Every week
Once a month
When required
Finish the Course
Only if necessary
Before meals
After meals
With food
On alternate days
At night only
As directed by your healthcare provider
Up to the maximum prescribed dose
Gradually increase or decrease the dose as instructed
1 Day Treatment
2 Days Treatment
3 Days Treatment
4 Days Treatment
5 Days Treatment
6 Days Treatment
7 Days Treatment
1 Week Treatment
2 Weeks Treatment
3 Weeks Treatment
4 Weeks Treatment
5 Weeks Treatment
1 Month Treatment
2 Months Treatment
3 Months Treatment
4 Months Treatment
5 Months Treatment
6 Months Treatment
12 Months Treatment
6
5ml Teaspoon
10ml
15ml
20ml
1 Tablet
2 Tablets
3Tablets
4 Tablets
5 Tablets
6 Tablets
7 Tablets
8 Tablets
9 Tablets
10 Tablets
11 Tablets
12 Tablets
13 Tablets
14 Tablets
15 Tablets
16 Tablets
17 Tablets
18 Tablets
19 Tablets
20 Tablets
21 Tablets
22 Tablets
23 Tablets
24 Tablets
25 Tablets
26 Tablets
27 Tablets
28 Tablets
29 Tablets
30 Tablets
31 Tablets
32 Tablets
33 Tablets
34 Tablets
35 Tablets
36 Tablets
37 Tablets
38 Tablets
39 Tablets
40 Tablets
Once a day
Immediately
At night
At bedtime
Twice a day
Three times a day
Four times a day
Every four hours
Every six hours
Every eight hours
Every twelve hours
Every twenty-four hours
Once a week
Every week
Once a month
When required
Finish the Course
Only if necessary
Before meals
After meals
With food
On alternate days
At night only
As directed by your healthcare provider
Up to the maximum prescribed dose
Gradually increase or decrease the dose as instructed
1 Day Treatment
2 Days Treatment
3 Days Treatment
4 Days Treatment
5 Days Treatment
6 Days Treatment
7 Days Treatment
1 Week Treatment
2 Weeks Treatment
3 Weeks Treatment
4 Weeks Treatment
5 Weeks Treatment
1 Month Treatment
2 Months Treatment
3 Months Treatment
4 Months Treatment
5 Months Treatment
6 Months Treatment
12 Months Treatment
7
5ml Teaspoon
10ml
15ml
20ml
1 Tablet
2 Tablets
3Tablets
4 Tablets
5 Tablets
6 Tablets
7 Tablets
8 Tablets
9 Tablets
10 Tablets
11 Tablets
12 Tablets
13 Tablets
14 Tablets
15 Tablets
16 Tablets
17 Tablets
18 Tablets
19 Tablets
20 Tablets
21 Tablets
22 Tablets
23 Tablets
24 Tablets
25 Tablets
26 Tablets
27 Tablets
28 Tablets
29 Tablets
30 Tablets
31 Tablets
32 Tablets
33 Tablets
34 Tablets
35 Tablets
36 Tablets
37 Tablets
38 Tablets
39 Tablets
40 Tablets
Once a day
Immediately
At night
At bedtime
Twice a day
Three times a day
Four times a day
Every four hours
Every six hours
Every eight hours
Every twelve hours
Every twenty-four hours
Once a week
Every week
Once a month
When required
Finish the Course
Only if necessary
Before meals
After meals
With food
On alternate days
At night only
As directed by your healthcare provider
Up to the maximum prescribed dose
Gradually increase or decrease the dose as instructed
1 Day Treatment
2 Days Treatment
3 Days Treatment
4 Days Treatment
5 Days Treatment
6 Days Treatment
7 Days Treatment
1 Week Treatment
2 Weeks Treatment
3 Weeks Treatment
4 Weeks Treatment
5 Weeks Treatment
1 Month Treatment
2 Months Treatment
3 Months Treatment
4 Months Treatment
5 Months Treatment
6 Months Treatment
12 Months Treatment
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