- Patient name & address as provided by patient or guardian
- Date the provider requested prescription
- Quantity of remaining refills and expiration date
- Name of prescribed Concentrated Decoction
5. Dosage instructions
6. Name and address of prescribing physician
7. Invoice number
8. Office use only
9. Off Label Use
- The name and address of the patient as provided by the patient/guardian on the order placed.
- The date that the prescribing physician submitted the prescription for patient.
- The number of refills left in the prescription before it expires. Each prescription comes with 8 refills in any 90 day period.
- The name of the Concentrated Decoction prescribed by physician.
- Dosage instructions as provided by physician.
- The name and address of the prescribing physician is provided here.
- The invoice number of the order placed by the patient.
- The Herbacy Prescription number, for in-office use only.
- If the dosage instructions differ from the suggested Si Jin Bao dosage amount, OLU (Off Label Use) will be signified. Physician accepts full responsibility of all OLU prescriptions.