No. of designated medical institution: x

Prescription No.: x8

Name: Scccccccc

Gender: female

Age: x

Patient No.: x

Charging type: common public expense

Clinic department: Mental Health Care Division

Diagnosis: anorexia x

Name of medicine

Specification and quantity

Detailed using method

Remarks

Fluoxertine hydrochloride dispersible tablets

20 mg* 28 tablets ×3.00 box

60 mg/oral taking 1/ daily/x days

Sensitivity test:

Pharmacy: outpatient pharmacy

Physician signature (seal):x

Amount of medicine: x.00 Yuan

Prescription date: 0x June 30, x4

Reviewed/deployed by (seal):

Checked/dispatched by (seal)