Original Prescription
Dr. Samuel Bernstein
3-C Medical Arts Building
Evelyn Johnson
1426 Pinecone Drive
7/24/20XX
Boniva 3 mg/3 mL Injection
Dispense 1 kit
Sig: Inject IV as directed every 3 months
3
Samuel Bernstein
DAW:
dispense as written
Prescription Origin Code: 1
Pharmacist Notes: drug to be administered in physician's office
Dispensing Documentation
Rx #: 841231
Dispensing Date: 7/24/20XX
Patient: Evelyn Johnson
Doctor: Samuel Bernstein
DEA: AB1294824
NDC: 00004-0191-09
RPh Initials: LDD
Drug: Boniva 3 mg/3 mL Injection
Manufacturer: Genetech
DAW Code: 1
SIG: INJ,UD,IV,into vein over 30 minutes, every 3 months
Fill Type: New
Fill Number: 1
Last Fill Date: 7/24/20XX
Refills Remaining: 3
Quantity: 3
Day Supply: 30
Drug Unit Cost: $175.66
Dispensing Fee: $1.75
Total Cost: $528.73
Signature Log
Signature:
Elmer Johnson
Rx Number:
841231
Fill Date Date:
7/24/20XX
Pick-up Date:
7/24/20XX
RPh Counseling:
Accept