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FREQUENT DISPENSING AUTHORIZATION FORM FOR LESS THAN 28 DAY SUPPLY Prescription Drug Program P.O. Box 690, Moncton NB E1C 8M7 PATIENT INFORMATION (Required) Patient Last Name Patient First Name NB
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How to fill out frequent dispensing form
How to fill out frequent dispensing form:
01
Begin by entering your personal information such as your name, address, contact number, and date of birth in the designated fields. This ensures accurate identification and communication.
02
Next, provide relevant medical information such as your healthcare provider's name, contact details, and any specific instructions related to your medication or treatment plan. It's important to include any allergies or underlying health conditions that may impact your medication regimen.
03
Specify the medication details by including the name, dosage, and frequency of each medication you are currently prescribed. This helps healthcare providers monitor your medication usage and ensure a proper supply is dispensed.
04
If there are any special instructions or precautions related to your medication, such as time-sensitive administration or dietary considerations, be sure to include them in the form. This ensures that the dispensing healthcare provider is aware of any specific requirements.
05
Lastly, sign and date the form to verify its accuracy and completeness. This serves as a confirmation that the provided information is correct and you take responsibility for adhering to the prescribed medication regimen.
Who needs frequent dispensing form:
01
Patients with chronic illnesses or long-term medical conditions who require regular and repetitive medication refills may need a frequent dispensing form. These forms help facilitate the dispensing process by providing comprehensive information about the patient's medication needs.
02
Individuals with complex medication regimens, involving multiple medications or frequent dosage adjustments, may also benefit from frequent dispensing forms. These forms help healthcare providers track medication usage and ensure a timely and adequate supply.
03
Patients who undergo specialized treatment plans that involve frequent medication changes or adjustments may require a frequent dispensing form. This allows healthcare providers to monitor and adjust the medication supply accordingly based on the patient's evolving needs.
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