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Get Baylor Scott & White Health Medication Reconciliation

This visit Information Source: □Patient □Caregiver/Family□ Other: _______ Unable to obtain due to □ Patient condition □ Patient’s knowledge of meds (Include all herbals, prescription, over the counter, eye drops, inhalers, vitamins and supplements) Given on Discharge P=Prescription Route How often taken Drug Name and Dosage DATE S=Samples The listed medications are correct. I, the undersigned, have read and understand these instructions. I understand if prescriptions are to be fill.

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