A controlled release dosage form is used by pharmacists, doctors and pharmaceutical companies to outline details of medicine being given out in controlled dosages. A controlled release dosage form needs to be well designed and have a clear and easy to understand format because of the delicate nature of medicine.
Sample Controlled Release Dosage Form
Patient’s name: ___________________________________________________________
Address: ________________________________________________________________
Tel number: _____________________________________________________________
Mobile number: __________________________________________________________
Email: __________________________________________________________________
Authorizing doctor’s name: _________________________________________________
Department: _____________________________________________________________
Date: ___________________________________________________________________
Signature: _______________________________________________________________
Description of the patient’s current condition:
________________________________________________________________________________________________________________________________________________
Please indicate details of the patient’s dosage requirements:
Liquid dosage:
Syrup: __________________________________________________________________
Suspension: _____________________________________________________________
Emulsion: _______________________________________________________________
Solid dosage:
Pill: ____________________________________________________________________
Tablet: _________________________________________________________________
Capsule: ________________________________________________________________
Eye drop: _______________________________________________________________
Nose drop: ______________________________________________________________
Inhaler: _________________________________________________________________
Implant: ________________________________________________________________
Patch: __________________________________________________________________
Ointment: _______________________________________________________________
Cream: _________________________________________________________________
Gel: ____________________________________________________________________
Paste: __________________________________________________________________
Lotion: _________________________________________________________________
Medicated soap: __________________________________________________________
Medicated shampoo: ______________________________________________________
Please indicate how the dosage should be administered:
Duration:
From: __________________________________________________________________
To: ____________________________________________________________________
Frequency: ______________________________________________________________
Patient’s signature: ________________________________________________________
