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FACILITY DISPOSITION OF MEDICATIONS FORM Resident s Name Room RX DRUG NAME AMOUNT LABEL DATE TYPE OF DISPOSITION MUST CHECK ONE Discharged with drugs To Nursing Office for disposal control drugs Destroyed Doses Removed From Emergency Drug Kit. DISCHARGED WITH DRUGS Signature of Nurse Releasing Medication I hereby accept medication s in non-childproof containers for the person in which they were prescribed. Medication s released will be submitted for payment per the Agreement for Pharmaceutical Services. FACILITY DISPOSITION OF MEDICATIONS FORM Resident s Name Room RX DRUG NAME AMOUNT LABEL DATE TYPE OF DISPOSITION MUST CHECK ONE Discharged with drugs To Nursing Office for disposal control drugs Destroyed Doses Removed From Emergency Drug Kit. DISCHARGED WITH DRUGS Signature of Nurse Releasing Medication I hereby accept medication s in non-childproof containers for the person in which they were prescribed* Medication s released will be submitted for payment per the Agreement for Pharmaceutical Services. TO NURSING OFFICE FOR DISPOSAL CONTROL DRUGS Signature of D. O. N* Receiving Medication NON-CONTROLLED DRUGS DESTROYED BY NURSING DESTROYED BY Signature Witness. DISCHARGED WITH DRUGS Signature of Nurse Releasing Medication I hereby accept medication s in non-childproof containers for the person in which they were prescribed* Medication s released will be submitted for payment per the Agreement for Pharmaceutical Services. TO NURSING OFFICE FOR DISPOSAL CONTROL DRUGS Signature of D. O. N* Receiving Medication NON-CONTROLLED DRUGS DESTROYED BY NURSING DESTROYED BY Signature Witness.

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