APOTHECARY & INFIRMARY RECORD

 

❖ APOTHECARY & INFIRMARY RECORD ❖

AR’S STATION

PHYSICIAN’S NOTICE: This document records the administration of restricted substances and the treatment of patients within the infirmaries of Ar’s Station.

I. THE MEDICAL AUTHORITY

• Physician Name/Account: ____________________

• Caste & Rank: ______________________________

II. PATIENT INFORMATION

• Subject Name: __________________ Status: [ ] Free [ ] Slave

• Diagnosis: _________________________________________________

III. MEDICINAL DISPENSATION

• [ ] Noble Wine: (For contraceptive/reproductive control)

• [ ] Slave Wine: (For contraceptive/reproductive control)

• [ ] Poisons/Toxins: (Reason for use: _________________________)

• [ ] Healing Salves/Tonics: ___________________________________

PHYSICIAN SIGNATURE: __________________ SEAL: [ ]

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