Staged supply record (single medicine)
Standard and guidelines for pharmacists providing a staged supply service for prescribed medicines
Name: ____________________________________________________ Phone: ____________________________________________
Address: ______________________________________________________________________________________________________
_______________________________________________________________________________________________________________
Start date: _________________________________________________ Prescriber: _________________________________________
Payment details: ________________________________________________________________________________________________
Medicine: ______________________________________________________________________________________________________
Dose: _________________________________________________________________________________________________________
Supply interval: _________________________________________________________________________________________________
Agreement details: ______________________________________________________________________________________________
Affix copy of dispensing label here:
Medicine
Notes, e.g. payment
Date
Time
Pharmacist
Consumer
No. days
No. tabs
Balance
due, script exp,
signature
signature
doctor contact
Carried forward
Pharmaceutical Society of Australia