Village Center For Wellness

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Patient Name_______________________________________________________________ Descriptions Vitamin / Herb (Name), Dosage, Frequency (how many pills, capsules,applications taken per day) Prescription Name Daily Dosage Freq/Day _______________________________________________________ _____________ _____________ _______________________________________________________ _____________ _____________ _______________________________________________________ _____________ _____________ _______________________________________________________ _____________ _____________ _______________________________________________________ _____________ _____________ _______________________________________________________ _____________ _____________ _______________________________________________________ _____________ _____________ _______________________________________________________ _____________ _____________ _______________________________________________________ _____________ _____________ _______________________________________________________ _____________ _____________ _______________________________________________________ _____________ _____________ _______________________________________________________ _____________ _____________ _______________________________________________________ _____________ _____________ PATIENT SIGNATURE______________________________________________Date________________ (Or patient representative, Indicate relationship, if signing for patient) OFFICE SIGNATURE_______________________________________________Date:________________

Village Center for Wellness - 5406 Village Road, Long Beach, CA 90808 - (562) 420-1585 Email: info@VillageCenterForWellness.com