John Daisy, DO

$123$ Maple Dr

Anywhere, US $00000$

$555-123-4567$

Name:

Steven Barrow

DOB

Address:

Date: $\frac{12}{15}\frac{?}{24}$

Augmentin Suspension $200mg$ bid $x10$ days

Albuterol Liquid $4mg10$ days

Refill $0$ times

Signature:

Dohn Daisy. DO

DEA#:

Generic will be dispensed unless box is checked.

#$6$

$72$