Medication Flow Sheet - Nc Division Of Public Health Page 2

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Patient Name, #, or DOB
Medication Flow Sheet
or
Attach Patient Label Here
9. /\ or DC
8. Date
11. Lot No./
13. Pt. Med Ed.
14. Prescriber’s
Date
10. Medication Name
12. Dose/ Rte./Frequency
15. Signature
(M/D/Y)
Manufacturer
(Source with Date)
Name
(M/D/Y)
16. Pharmacy Name /Telephone Number
DHHS 2802 (Revised 07/04)
PHNPD (Review 07/07)
Page _____

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