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Use Student ID for NZMC.No. Case: (-( DSM/UOW (delete onek Group: + Pharmacy Use Only stem count 2 UOW Medical Centre, 17 Learning Dr, Wellington Ph: 123.4567 prescription Subsidy NZMC RENO? «PEAS ZI oe — ref patent rarmacy stamp -Me-Master Aig Mise-Mis-Or One exemple Fa eos pot [S Selon Se Che skewer ate of bth if patent under 1) NHI: Fibupeles Joong TT tas pin pean mite. '/s2 mm Re Signature of prescriber C- [hal Date: ae B24 13 | wud alo be witten 26 &. ibepreotn 20mg [+2 +ebueAt ree tives deity HF nected he pain re _weele Supply oe & ibuprten oomg teblets 2oo-yoomg 3* aaity es vequied for mite: 42 4oblett pan < preseyiphan must be legble ant cartes tees nane anct SNENS IH ot Me pecicrn dor and CequeMies_Miss-Ms-Br Secona _Exeypn ple Tall ester oes ofan BS Seteqn Sb Cnviskevovets bate of bith patent under 33:.2( (2 | 2504 _| wut B iopeten toamg (Smo - ISomg tele eager leg sugeg —'IS2 eam Re Signature of prescriber" JAxcien~ A [ Date: 32 J 7 This is on erenpie ot how to prescribe. a Uqusc. 4 coud alo be writer os: ibupleken loo me / Se WS we twee three a Aeg lOmg (ng (dose wag? (Shs er on Ibegrets 00mg /Sme weight Sh TVSme th (emg |ug lacie Supply ore _weele This yon exenpre of PREM EAG rece. Hers on ove Peripher. Ht belphl ts Phe pherrmracst te know That a darge 1 Aske heb occured They cen okt enprasia tis chen ge ChristéhurA when Cone G he pohert. Date of bith ff patient under 13): NHI: ° Re fipoenuce HOM 2 tabs mane SS, Aope Suey Aha . RE conezcle 24, creer Bamples of presen an @clerral meciore eco fo fet 20 all f you prescribe 0 pevicd of spply, ob iu als! # is2 WnportantA ts ensure gow heave gpeuhéed © Aqueo, creons bere he cram fortrent serng uid so Sap Subshktile pra Det he photmrocst can eleutake or Ie SOT, aperpintc amount te spy : ca) Signature of prescriber; (Auctp a bate PT t

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