Prescription	Select Prescription   Click to Select eRx ID# 01 eRx ID# 02 eRx ID# 03 eRx ID# 04 eRx ID# 05 eRx ID# 06 eRx ID# 07 eRx ID# 08 eRx ID# 09 eRx ID# 10 eRx ID# 11 eRx ID# 12 eRx ID# 13 eRx ID# 14 eRx ID# 15
Patient	Select Patient   Click to Select *New Patient Bontrager, Stanley M.Bontrager, Coleen L.Bontrager, Julia M.Bontrager, David M.Bontrager, Joel N.Bontrager, Rose J.Bruno, Kyle O.Bruno, Elizabeth R.Bruno, Billy JoeDay, DanielDay, GloriaElder, RobertElder, Georgia L.Elder, Charles O.Elder, Laurie N.Elder, Mrs. HaroldGarcia, CarlosGarcia, AndreaGarcia, GabrielaGarcia, MaríaGarcia, JuanHanson, Richard T.Hanson, Lily M.Hanson, James R.Hanson, William B.Hanson, Mary JeanJohnson, ElmerJohnson, EvelynJones, William P.Jones, Sylvia F.Jones, Janet T.Khan, OmarKhan, FayrahKhan, PhoebeMiller, Edward M.Miller, Judy J.Miller, Jim S.Miller, Jill J.Moore, George S.Moore, Betty L.Moore, Wendy J.Moore, AnnaMorgan, John R.Morgan, MargaretMorgan, Hilda R.Mott, Edward G.Mott, Mary F.Mott, Jim O.Mott, Jill S.Mott, Tim D.Mott, JulieNguyen, VanNguyen, TrangNguyen, TranNguyen, AnhNguyen, DucNguyen, NgocNguyen, NhiRoberts, RobertaRoberts, RobertRoberts, RobbieRoberts, RobinSawyer, MarkSawyer, AliceSykes, Bob O.Sykes, Teresa C.Williams, AlexanderWilliams, BeverlyWilliams, WilliamWilliams, GinaWilliams, AudreyWong, ZhangWong, SunnyWong, LilyWong, LiWright, Don Q.Wright, Elizabeth A.Wright, Mary S.   Prescription Insurance: Cash - no third party insurance Third Party Insurance/Coupon
Prescriber	Select Prescriber   Click to Select *New Prescriber Carolyn Abman, MDSamuel Bernstein, MDSherman F. Fleer, DDSHarold L. Green, MDSandra Jones, DONorman Keyes, MDCynthia McDonald, MDGeorge Platz, MDRoyal T. Shumway, MDJames T. Warren, MD
Drug	Pharmacy DAW Code   Click to Select ---------------------------------------------- 0 - No Product Selection Indicated 1 - Substitution Not Allowed by Prescriber ---------------------------------------------- 2 - Substitution Allowed-Patient Requested Product Dispensed 3 - Substitution Allowed-Pharmacist Selected Product Dispensed 4 - Substitution Allowed-Generic Drug Not in Stock 5 - Substitution Allowed-Brand Drug Dispensed as a Generic 6 - Override 7 - Substitution Not Allowed-Brand Drug Mandated by Law 8 - Substitution Allowed-Generic Drug Not Available in Marketplace 9 - Substitution Allowed By Prescriber but Plan Requests Brand
	Drug Name
	DEA Schedule    Not a Controlled Substance CII CIII CIV CV
SIG
Qty & Refills	Quantity Prescribed      Days Supply      Refills
Dates	Date Rx Written (MM/DD/YYYY, use current year)      Date Rx Expires (MM/DD/YYYY, from current year)
Documentation	Prescription Origin Code    Click to Select 1 - Written 2 - Telephone 3 - Electronic 4 - Facsimile 5 - Pharmacy Transfer 5 - Pharmacy