Original Prescription
Mary F. Mott
906 Harvard
3/4/20XX
Aldara 5% Topical Cream
Dispense 12 packets
Sig: Apply 2 times per week at HS for actinic keratosis
2
James T. Warren
3-G Medical Arts Building
Tina Jarboe
dispense brand only
Prescription Origin Code: 2
Pharmacist Notes:
Dispensing Documentation
Rx #: 301421
Dispensing Date: 5/6/20XX
Patient: Mary F. Mott
Doctor: James T. Warren
DEA: AW1351977
NDC: 99207-0260-12
RPh Initials: SJM
Drug: Aldara 5% Topical Cream
Manufacturer: 3M
DAW Code: 1
SIG: A,thin layer,AA,2 times per week (each dose 3-4 days apart) just prior to sleep for actinic keratosis
Fill Type: Refill
Fill Number: 3
Last Fill Date: 4/3/20XX
Refills Remaining: 0
Quantity: 12
Day Supply: 30
Drug Unit Cost: $21.05
Dispensing Fee: $1.75
Total Cost: $254.35
Signature Log
Signature:
Mary Mott
Rx Number:
301421
Fill Date Date:
5/6/20XX
Pick-up Date:
5/7/20XX
RPh Counseling:
Decline