| No. of designated medical institution: x | Prescription No.: x8 | |
| Name: Scccccccc | Gender: female | Age: x |
| Patient No.: x | Charging type: common public expense | Clinic department: Mental Health Care Division |
| Diagnosis: anorexia x | |||||
| Name of medicine | Specification and quantity | Detailed using method | Remarks | ||
| Fluoxertine hydrochloride dispersible tablets
| 20 mg* 28 tablets ×3.00 box | 60 mg/oral taking 1/ daily/x days |
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| Sensitivity test: | Pharmacy: outpatient pharmacy | Physician signature (seal):x | |||
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| Amount of medicine: x.00 Yuan | Prescription date: 0x June 30, x4 | Reviewed/deployed by (seal): | Checked/dispatched by (seal) |
* Tips of pharmacist: Please take the medicine according to doctor’s advice. The prescription is valid within three days. Please count the medicine at the counter. The medicine dispatched cannot be replaced.