HOSPITAL PHARMACY

1234 MAIN STREET

ANYWHERE, ILLINOIS

DEA NO. XX 0000000

PHONE NO.  (     ) 000-0000

RO NO:

123-456

PHYSICIAN:

JOHN DOE

DATE: 10-10-80

ONE CAPSULE EVERY SIX HOURS AS NEEDED.

DELTA-9-THC

5MG (#25)

VALID FROM 10-10-80 to 10-20-80

(RPH INITIALS)

CAUTION:  FEDERAL LAW PROHIBITS THE

TRANSFER OF THIS DRUG TO ANY PERSON

OTHER THAN THE PATIENT FOR WHOM IT

WAS PRESCRIBED.

THIS PRESCRIPTION CANNOT BE REFILLED

RETURN UNUSED PORTION TO DISPENSING

PHARMACY FOR PROPER DISPOSAL.

KEEP OUT OF REACH OF CHILDREN.  IN CASE

OF ACCIDENTAL OVERDOSE, CONTACT A

PHYSICIAN IMMEDIATELY.