DR. BONIFACIA V. ALBANO MEMORIAL HOSPITAL Bacarra, Ilocos Norte

MEDICATION INSTRUCTIONS

Name:_________________________________________ Date of Admission:______________________Address:_______________________________________ Date of Discharge:_______________________Diagnosis:______________________________________ Attending Physician:_____________________

Medication Morning Lunch Afternoon Bedtime Remarks

Additional Instructions:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Follow-Up Check Up: _____________

TB DOTS PERSONNEL:______________________

DR. BONIFACIA V. ALBANO MEMORIAL HOSPITAL Bacarra, Ilocos Norte

MEDICATION INSTRUCTIONS

Name:_________________________________________ Date of Admission:______________________Address:_______________________________________ Date of Discharge:_______________________Diagnosis:______________________________________ Attending Physician:_____________________

Medication Morning Lunch Afternoon Bedtime Remarks

Additional Instructions:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Follow-Up Check Up: _____________

TB DOTS PERSONNEL:______________________

DBVAMH - NS 019

DBVAMH - NS 019