Fillable PHARMACY DISPENSING RECORD PLEASE PRINT A PATIENT INFORMATION (Death With Dignity)

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PHARMACY DISPENSING RECORD PLEASE PRINT A PATIENT INFORMATION (Death With Dignity)

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PLEASE PRINT
SEND A COPY OF THIS FORM TO THE OREGON STATE PUBLIC HEALTH DIVISION
PHARMACY DISPENSING RECORD
ORS 127.800 - ORS 127.897
MAIL FORM TO: Center for Health Statistics,
Oregon State Public Health Division, P.O. Box 14050, Portland, OR 97293-0050
PLEASE PRINT
A PATIENT INFORMATION
PATIENT’S NAME (LAST, FIRST, M.I.): DATE OF BIRTH:
B PHYSICIANINFORMATION
NAME (LAST, FIRST, M.I.): TELEPHONE NUMBER:
MAILING ADDRESS:
CITY, STATE AND ZIP CODE:
C DISPENSING HE
A
LTH CA
R
E PROVIDER INFORMATION
NAME (LAST, FIRST, M.I.): TELEPHONE NUMBER:
MAILING ADDRESS:
CITY, STATE AND ZIP CODE: DATE OF THIS REPORT:
D MEDICATIONS DISPENSED
MEDICATIONS QUANTITY DATE PRESCRIBED DATE DISPENSED
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Copies of this form are available at: http://www.healthoregon.org/dwd
Rev. 11/15
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PHARMACY DISPENSING RECORD PLEASE PRINT A PATIENT INFORMATION (Death With Dignity)

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Completed 11 March 2021

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