Original Prescription
James R. Hanson
1205 Edgewood Lane
5/9/20XX
Xyzal 0.5 mg/mL Solution
Dispense 5 ounces
Sig: i tsp PO QD
5
Harold L. Green
2-G Medical Arts Building
Darcie Smith
dispense brand only
Prescription Origin Code: 2
Pharmacist Notes:
Dispensing Documentation
Rx #: 784119
Dispensing Date: 8/12/20XX
Patient: James R. Hanson
Doctor: Harold L. Green
DEA: AG1294230
NDC: 00024-5801-21
RPh Initials: CPL
Drug: Xyzal 2.5 mg/5 mL Oral Solution
Manufacturer: Sanofi Aventis
DAW Code: 1
SIG: T,1,TSP,(5 mL),PO,QD
Fill Type: Refill
Fill Number: 3
Last Fill Date: 7/9/20XX
Refills Remaining: 3
Quantity: 148
Day Supply: 30
Drug Unit Cost: $0.69
Dispensing Fee: $1.75
Total Cost: $103.87
Signature Log
Signature:
Lily M. Hanson
Rx Number:
784119
Fill Date Date:
8/12/20XX
Pick-up Date:
8/12/20XX
RPh Counseling:
Decline