|
Phentermine
|
|
|
Dose?
|
Days refilled?
|
|
Phendimetrazine
|
Days refilled?
|
|
HCTZ
|
Days refilled?
|
|
Fat Burners
|
Days refilled?
|
|
Zofran
|
Quantity refilled?
|
|
Diucaps
|
Days refilled?
|
|
Notes:
|
|
|
Signed off by:
|
|
