| 摘要 |
A combination preselected medication sample prescription form, sample payment check, and medication sample regulating device includes a support panel having an obverse and a reverse surface and defines first, second and third portions thereof. An area for receiving written, printed or typed patient identification information is viewably applied over the obverse surface of the first portio n which also includes a medication prescription form, the entire first portion being detachable from the adjacent second portion along a transverse tear line of weakness. T he second portion, positioned on the support panel centrally between the first and third portions, includes manufacturer's product information printed on both the obverse and the reverse surfaces thereof. The third portion includes a preprinted payment check for a sample quantity or as a partial payment for a larger quantity of preselected medication. This combination permits the physician to simultaneously begin the process of distributing a sample quantity of the preselected medication and to write a prescription for any quantity therefor.
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