Self Assessment
Choose Consent Form
Prescription

Prescription

Patient’s Name:

File No.:

DOB:

Mobile Number:

Visit Date:

Registration Time:

Doctor Name:

- Tab.Zinnat 500mg (1+1) 5days
- Tab. Panadol 500mg (1+1+1) 3days
- Tab.Gupisone 5 mg (2+2+2) 3 days
- Fucidin ointment 30g (Apply on the donor area after removing the bandage for 2days)

Patient Name & Signature :

Doctor/Therapist Name & Signature :

Witness Name & Signature :

Parent or Gaurdian Name (if patient is minor) :

Patient Name & Signature :