Atropine Eye Drops Template

Prescription Template

400 Taché Ave, Winnipeg, MB R2H 2A4
Phone: (204) 233-3469 Fax: (204) 231-1739

Patient

Name

DOBSexMF

PHIN

Phone

Date

Ophthalmic Drops

Check strength

Atropine

0.05% 0.025% 0.02% 0.01% 0.1% %

Other strengths can be compounded on request.

Quantity

5 mL 10 mL or mL

Refills

1 2 3 or

Directions Instill 1 drop into each eye daily at bedtime

Name	Clinic
Phone	Fax

Signature