	MEDICAL DEPARTMENT



	PRESCRIPTION

MRN:	EMPLOYEE ID:
PATIENT NAME:	FATHER'S NAME:
AGE: y : "Not Available"; ?>	GENDER:
DIVISION:	DEPARTMENT:
AREA/SECTION:
IN TIME:	CLEARANCE TIME:

Signature & Stamp

PREVENTION IS BETTER THAN CURE

NOTE: NOT FOR USE MEDICO LEGAL PURPOSES