Facility name
123 Some Street
Anytown, ST 12345
DEA# AB0123456
(123)456-7890
Last, First
MRN: ########
DoB: MM/DD/YYYY
cyclophosphamide 0 mG
0 mL
in 0.9% Sodium Chloride
100 mL
Total volume: 100 mL
Rate: 100 mL / hr
Infuse over 1 hour(s)
Exp: MM/DD/YYYY hh:mm
Prep: MM/DD/YYYY hh:mm
Verify: ____
Fill: ____
Check: ____
* * * FOR COMPOUNDING ONLY * * *
Last, First
MRN: ########
DoB: MM/DD/YYYY
Cyclophosphamide 500 mG / 25 mL vial
0 mL
0.9% Sodium Chloride bag
100 mL
Total volume: 100 mL
Exp: MM/DD/YYYY hh:mm
Prep: MM/DD/YYYY hh:mm
Verify: ____
Fill: ____
Check: ____