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BC Controlled Prescription Form.

Fill in the drug, doses and dates, and get the BC controlled prescription (triplicate) form with quantities written in numbers and words. The prescriber adds the patient details and signs it by hand.

Drug

Prescribed for

Doses

Add each dose in order. A single row is a steady dose.

Witnessed ingestion

Number of days per week of daily witnessed ingestion

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Controlled Prescription Program

British Columbia
Patient PHNPrescriber completes
Date (dd / mm / yyyy)
Patient namePrescriber completes
Address and cityPrescriber completes
Drug name, strength
Total quantity
Start → end (dd / mm / yyyy)
Daily dose
Days per week witnessed
Directions
Prescriber name, ID and signaturePrescriber completes and signs
Created with www.oatrx.caPrints as two copies