Patient Name: ___________________________________________ DOB: ____________________

Lorazepam 0.5 mg tablets 1 tab by mouth or sublingual every 2 hours PRN anxiety.
     May repeat ×1 in 30 minutes if the pain remains anxious. #10 pills

Haloperidol 1 mg every 4 hours PRN for agitation may repeat ×1 pill in an hour if unrelieved.
    #5 pills

Hyoscyamine 0.125 mg sublingual every 4 hours PRN for excess secretions #10 pills

Morphine sulfate elixir, 20 mg per mL 5 mg either by mouth or sublingual every 2 hours PRN
     for pain or shortness of breath #30 mL

Tylenol 650 mg suppositories, 1 suppository PR every 6 hours PRN temperature greater than
     100° as needed for mild pain or fever

Physician Signature: ______________________________________ Date: _____________________

Samuel T. Bowen, MD
DEA: BB0930366
NPI: 1568448439
License:
NC 003115
VA 0101260751