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
#1
#2
#3
#4
Copies of this form are available at: http://www.healthoregon.org/dwd
Rev. 11/15