Low-Dose Naltrexone Template
Prescription Template
400 Taché Ave, Winnipeg, MB R2H 2A4
Phone: (204) 233-3469 Fax: (204) 231-1739
Patient
SexMF
Capsules
Check strength
Naltrexone
1 mg
1.5 mg
2 mg
3 mg
4.5 mg
mg
Other strengths can be compounded on request — allow up to two business days.
Quantity
30 capsules
60 capsules
90 capsules
or
capsules
Refills
1
2
3
or
Directions
Take 1 capsule once daily as directed
or
Prescriber
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Signature