Vietnam: Medicine prescription form according to Circular 18/2018/TT-BYT for replacement

Unit name…………….

Phone number……………...

PRESCRIPTION

Full name…………. Age.......... Weight......... male/female……..

Health insurance card number (if any)……………………….

Contact address ………………………………………………….

Diagnosis………………………………………………………

Treatment drugs:

INSTRUCTIONS FOR FILLING PRESCRIPTIONS
1. White paper, Times New Roman font size 14, black color.
2. The form is used for prescribing drugs (except narcotic drugs, psychotropic drugs).
3. Phone number: record the phone number of the medical examination and treatment facility or of the department or the prescribing doctor/physician.
4. Age: record the patient's age, for children under 72 months, record the number of months.
5. Weight (must be recorded for children under 72 months old): can weigh the child or ask the child's parent or the person bringing the child for medical examination and treatment.
6. The name of the child's father or mother or the person bringing the child for examination and treatment (only recorded for children under 72 months old): ask the person bringing the child for examination.
7. Contact address: record the patient's address so that the medical examination and treatment facility can contact and exchange information when necessary.
8. Instructions:
- Nutrition regime and work activity policies
- Follow-up appointment (if necessary).

Instructions:

Date…… Month…… Year 20.....

Doctor/Physician conducting the examination

(Signature, full name)

- Please bring this form with you for the follow-up appointment.

- The name of the child's father or mother or the person bringing the child for medical examination and treatment ………………………………………………………………………