The full name of the patient.
The address of the patient for active duty patients only.
The date the prescription was written.
The name of the medication.
The strength of the medication.
The refill instructions.
(7) The statement "TO BE FILLED ONLY AT (name of local medical
treatment facility) PHARMACY"--if the prescription were written by a nurse clinician or
graduate physician assistant. (NOTE: The other types of physician extenders are not
authorized to prescribe controlled medications.)
The signature of the prescriber--signed in ink on the day the prescription
The rank and degree of the prescriber.
(10) The branch of service of the prescriber.
(11) The social security/service number of the prescriber.
(12) The name of prescriber stamped, typed or hand printed on the
MULTIPLE ITEM PRESCRIPTION FORM
a. Commanders of Medical TX Facilities may authorize the use of locally
developed multiple prescription form on an interim basis until either an OD or DA form is
published. However, multiple prescription blanks provided by or preprinted by a
commercial company will not be used in Army MTFs.
b. The multiple item prescription form (AF Form 781) can be used to prescribe
more than one non-controlled medication. A prescriber should not use this form to write
for controlled medications because of the filing problems that the pharmacy would face
(See paragraph 3-17, page 3-25 of this subcourse) with the prescription. The
information required on the form (for both controlled and non-controlled medications) is
the same as the information required on DD Form 1289. A completed multiple item
prescription form (AF Form 781) is shown in figure 3-4.