Abbotsford
604-755-4408
Surrey
778-218-4100
BC Controlled Prescription Form.
Prescription Date
*
DRUG NAME (MG)
*
METHADOSE 10 MG/ML
METADOL – D 10 MG/ML
SUBOXONE
KADIAN
DILAUDID
OTHER
1mg
2mg
4mg
8mg
Start Date
*
Dose in mg
Frequency
OD
BID
TID
QID
Number of Days Authorized
ADD
End Date
*
Total Quantity On Prescription
*
Total Number Of Days
Number of days per week of daily witnessed ingestion
Daily
Carries
No Witness
6
5
4
3
2
1
Other
Special Instruction
Submit
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