PARKWAY PHARMACY
Facility Date MEDICATION DISPOSITION SHEET
PHARMACY USE ONLY
CREDIT ISSUED
Rx# Qty
Disposed
Reason
(See Key)
Qty Rec'd No (see_key) Yes Initials
DISPOSITION REASON KEY: CREDIT DENIAL KEY:
A - Deceased (Return to Rx) E - Overstock (Return to RX) Form Completed By: Title: 1 - Controlled Substance 7 - Defaced Packaging
B - Med Discontinued (Return to Rx) F - Released to Customer 2 - Altered Dosage 8 - Below Minimum
C - Discharged (Return to Rx) G - Temporary Discharge Witnessed By: Title: 3 - Products requiring refrigeration 9 - Insufficient Shelf Life
D - Destroyed - (If Destroyed indicate date below: H - In Hospital 4 - ANY product over 60 days from dispensing date 10 - Manager's Option
I - Other - type in below Witnessed By: Title: 5 - Vials 11 - Per Diem Contract
6 - Third Party 12 - OTHER ________
Pick-Up: (Pharmacy Representative) Date: Facility Acknowledgement: Title: