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RESTRICTED MEDICATION PRESCRIPTION 

Incident No.: Station: Date: Time:
Patient Name Age Gender
Diagnosis:
S.No Drug Name 1st Dose 2nd Dose
Dose Time Route Dose Time Route
1 Inj.Morphine Sulphate 10mg/1ml
2 Inj.Diazepam (Valium) 10mg/2ml
3 Inj.Midazolam (Dormicum) 15mg/3ml
4 Inj.Fentanyle 100mcg/2ml
5
Administered By: Force No.: Signature: 
Witnessed By: Force No.: Signature:
Medication Discarded
Drug: Dose discarded: Time:
Discard By: Force / Staff No: Signature:
Witnessed by: Force / Staff No: Signature:

Note:

  1. This prescription need to be signed by both EMT's personnel and will need to be counter signed by the notified duty supervisor or medical director.
  2. Any unused medication should be discarded immediately in the hospital in front of nurses or doctors and for the person to sign as witnessed.
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