| 摘要 |
A combination preselected medication sample prescription form, sample payment check, and medication sample regulating device includes a support panel having an obverse or front facing surface which defines a first and second portion thereof. An area for receiving written, printed or typed patient identification information is viewably applied over the first portion and a removable medication prescription form is attached over the second portion of the support panel. The second 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. The preferred embodiment also includes a manufacturers product information sheet removably attached to either the support panel or the prescription form, or between both.
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