OAT Log & Daily Witnessed Ingestion Record – Pill4Me Pharmacy, Chilliwack

BC OAT Prescription → Daily Log Generator

Patient Name

Drug / Formulation

Start Date

End Date

Total Daily Dose (mg)

Dispensing Mode

Witnessed Days per Week

Week Starts On

Default Rx/Txn #

Default Delivery Address

Default Delivery Time

NOT AUTHORIZED FOR DELIVERY

Patient Name:

Drug / Formulation: — Total Daily Dose: — Total Rx Dose: —

Date Dispensed	Prescription or Transaction Number	Quantity			Delivery Information		Accountability	Patient’s signature
		Witnessed	Take Home	Total	Address	Time