Original Prescription
at 9:18, eRx #: 4653
ELECTRONIC PRESCRIPTION
Edward G. Mott
906 Harvard
Date: 3/10/20XX
Captopril 50 mg Tablet
Dispense 1 month
Sig: i po QD for high blood pressure
Refills: 11
Dr. Samuel Bernstein
3-C Medical Arts Building
AB1294824
DAW:
Prescription Origin Code: 3
Pharmacist Notes:
Dispensing Documentation
Rx #: 210035
Dispensing Date: 10/16/20XX
Patient: Edward G. Mott
Doctor: Samuel Bernstein
DEA: AB1294824
NDC: 68645-0162-59
RPh Initials: ASD
Drug: Captopril 50 mg Tablet
Manufacturer: Wockhardt
DAW Code: 0
SIG: T,1,PO,QD,for,HBP
Fill Type: Refill
Fill Number: 7
Last Fill Date: 9/13/20XX
Refills Remaining: 5
Quantity: 30
Day Supply: 30
Drug Unit Cost: $8.16
Dispensing Fee: $1.75
Total Cost: $246.55
Signature Log
Signature:
Edward Mott
Rx Number:
210035
Fill Date Date:
10/16/20XX
Pick-up Date:
10/17/20XX
RPh Counseling:
Decline