American College of Physicians | Internal Medicine | ACP
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| |INJECTIBLE MEDICATION LOG | |
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|MEDICATION ___________________________________ |MEDICATION ___________________________________ |
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|EXPIRATION DATE: _________/_________/_________ |EXPIRATION DATE: _________/_________/_________ |
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|MANU/LOT ______________________________________ |MANU/LOT ______________________________________ |
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|SITE _____________________ DATE _________________ |SITE _____________________ DATE _________________ |
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|VIS date_______________ |VIS date_______________ |
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|CONSENT SIGNATURE: ____________________________ |CONSENT SIGNATURE: ____________________________ |
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|ADMIN. SIGNATURE ____________________________ |ADMIN. SIGNATURE ____________________________ |
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|MEDICATION ___________________________________ |MEDICATION ___________________________________ |
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|EXPIRATION DATE: _________/_________/_________ |EXPIRATION DATE: _________/_________/_________ |
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|MANU/LOT ______________________________________ |MANU/LOT ______________________________________ |
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|SITE _____________________ DATE _________________ |SITE _____________________ DATE _________________ |
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|VIS date_______________ |VIS date_______________ |
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|CONSENT SIGNATURE: ____________________________ |CONSENT SIGNATURE: ____________________________ |
| | |
|ADMIN. SIGNATURE ____________________________ |ADMIN. SIGNATURE ____________________________ |
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|MEDICATION ___________________________________ |MEDICATION ___________________________________ |
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|EXPIRATION DATE: _________/_________/_________ |EXPIRATION DATE: _________/_________/_________ |
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|MANU/LOT ______________________________________ |MANU/LOT ______________________________________ |
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|SITE _____________________ DATE _________________ |SITE _____________________ DATE _________________ |
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|VIS date_______________ |VIS date_______________ |
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|CONSENT SIGNATURE: ____________________________ |CONSENT SIGNATURE: ____________________________ |
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|ADMIN. SIGNATURE ____________________________ |ADMIN. SIGNATURE ____________________________ |
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Label or
Name:________________________________________
DOB:_____/______/________
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