Village Center For Wellness


Patient's Medical Prescriptions List

Patient Name_______________________________________________________________
Descriptions (Name), Dosage, Frequency (how many pills, capsules,applications taken per day)

Prescription NameDaily DosageFreq/Day
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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: VillageWellness@Verizon.net