Submission No.
Medical Prescription
Full Name
First Name
Last Name
Age
Gender
Please Select
Male
Female
N/A
Contact Number
Please enter a valid phone number.
Format: (000) 000-0000.
Nationality
Height
BMI
B.P
Pulse
SpO2
Temperature
Fahrenheit
RBS
Chief Complaint
Allergies
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Drugs
TABLETS
Tablets
CAPSULES
CAPSULES
SYRUPS
CREAM
1
Dosage
Rows
Morning
Afternoon
Evening
Night
Apply
1/4
1/2
1
2
3
1/4
1/2
1
2
3
1/4
1/2
1
2
3
1/4
1/2
1
2
3
DROPS
FOOD & NUTRITION
FOOD & NUTRITION
Please Select
Diasure Diabetic 400g
Isocal 425g
Ladymil (Vanila) 400g
Nan 2 (6-12) Months 400g
Nan Pre Mature 400g
Resource Diaabetic (Vanila) 400g
Sustacal 400g
Dosage
Rows
Morning
Afternoon
Night
Apply
2
3
4
NOTES
INJECTION
INJECTION
Please Select
Aciloc 25 mg
Adrenaline
Adrenaline (Martindale) 1mg/ml
Amiodarone 150 mg
Asthelin Res Solution
Atropine
Buscopan 1ml
Calcium Gluconate 10% w/v
Depo Medrol 40mg
Dextrose 5% 0.45 %Nacl
Dextrose 50%
Distilled Water 10
Dobutamine 12.5mg
Dopamine 200mg New
Dormicum 15mg/3ml
Emeset 4mg
Emeset 4mg/2ml (Inw) 4mg
Hartmanns Solution 500ml
Hydrocortazon 100 mg
Ipravent Solution 15ml
Lasix 20mg/2ml 20mg/2ml
Magnesium Sulfate 5g/10ml 5g/10ml
Normal Saline (Fresenius Kabi) 500ml
Novomix 30 Flexpen
Novomix Penfill 30
Pantazol 40 mg
Piriton
Piriton (Chlorphenamine) (Inw)10
Polybion Iv
Pulmicort
Sodium Bicarbonate (Martindale) 8.4%10ml
Tetanus Vaccine
Tranexamic Acid (Tranamic) 500mg
Tuberculin (Mantoux) 5in/1ml 5 iu/1ml
Ventolin Respiirator
Verapamil 5mg
Vit D3
Xylocaine 30ml
INJECTION
Please Select
Aciloc 25 mg
Adrenaline
Adrenaline (Martindale) 1mg/ml
Amiodarone 150 mg
Asthelin Res Solution
Atropine
Buscopan 1ml
Calcium Gluconate 10% w/v
Depo Medrol 40mg
Dextrose 5% 0.45 %Nacl
Dextrose 50%
Distilled Water 10
Dobutamine 12.5mg
Dopamine 200mg New
Dormicum 15mg/3ml
Emeset 4mg
Emeset 4mg/2ml (Inw) 4mg
Hartmanns Solution 500ml
Hydrocortazon 100 mg
Ipravent Solution 15ml
Lasix 20mg/2ml 20mg/2ml
Magnesium Sulfate 5g/10ml 5g/10ml
Normal Saline (Fresenius Kabi) 500ml
Novomix 30 Flexpen
Novomix Penfill 30
Pantazol 40 mg
Piriton
Piriton (Chlorphenamine) (Inw)10
Polybion Iv
Pulmicort
Sodium Bicarbonate (Martindale) 8.4%10ml
Tetanus Vaccine
Tranexamic Acid (Tranamic) 500mg
Tuberculin (Mantoux) 5in/1ml 5 iu/1ml
Ventolin Respiirator
Verapamil 5mg
Vit D3
Xylocaine 30ml
NOTES
LOCAL APPLICATION
LOCAL APPLICATION
Please Select
Ace-Suppository 125mg
Beclomin Lotion
Betadene Gargle 100 ml
Betadine Solution 100 ml
Candid V3
Candid V6 100 mg
Corsodyl Mouthwash
Diclovin 50mg 50mg
Diclovin Supp 12.5mg
Kleen Enema 135 ml
Micro Enema 10 ml
Preethi Conderm
Voltaren Suppo-100mg
Vomin Suppo 10
Vomvin 30mg
X-Oil
Zycolax 10mg
Zycolax 5mg
Dosage
Rows
Morning
Afternoon
Night
Apply
5
6
7
Notes
SPRAY
SPRAY
Please Select
Avamys N/S
Farmactive Silver 125ml
Fluticone 50 mcg
Nasoclear
Nazoline 0.05
Nitril 0.4 mg
Nitrosol 400mcg
Salonpas
Seratide Evohaler 125/25 mcg
Notes
VACCINE
VACCINE
Please Select
Influvac Tetra Vaccine 0.5ml
Dosage
Rows
Morning
Afternoon
Night
Apply
8
9
10
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Lab Tests
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