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Triplicate Prescription Writing Template
Emergency Fax Controlled Prescription
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Emergency Fax Controlled Prescription Program Form Documentation
Prescriber Name
Prescriber directory
Prescriber ID
Patient Name
Pharmacy
Select Pharmacy
Pharmacist
Pharmacy Name
Pharmacy Address
Fax
Phone
select from options
Brief description of the emergency situation:
Date
Signature Date
Reset
Generate Print
Edit Pharmacy
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Select Pharmacy
Name, City
Prescriber directory
×
Select Prescriber
Last Name, First Name
Select options for description of the emergency situation
×
Telehealth consultation, physician allowed prescription to be faxed (Original prescription will be mailed)
In-Person consultation, physician allowed prescription to be faxed (Original prescription will be mailed)
Prescription extended, to maintain continuity of care (Original prescription will be mailed)
Appointment time work schedule conflict, prescription faxed (Original prescription will be mailed)
Next appointment
Date
Time