| Resident Name:______________________ | ||||||||||
| Date Started Date Started | Date Stopped | Dosage, Dosage Times | Given by (initials) Given by (initials) | Comments Comments | Prescribing Physician Prescribing Physician | Physician Phone/Fax Physician Phone/Fax | Pharmacy Phone/Fax Pharmacy Phone/Fax | DRUG ALLERGIES DRUG ALLERGIES | Refill Number | |