Staged supply record (multiple medicines)
Standard and guidelines for pharmacists providing a staged supply service for prescribed medicines
Name: _________________________________________________________________________________________________________
Phone: ________________________________________________________________________________________________________
Address: _______________________________________________________________________________________________________
Prescriber: _________________________________________________ Start date: _____/_____/______
Payment details:)
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
Agreement details:
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
Affix dispensing labels here:
Pharmaceutical Society of Australia