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Integrating Primary Care Practices and Community-based Resources to Manage Obesity

Tool 9.聽Sample Prescription Pad

The sample pad shows the Living Well logo with phone number (541-322-7430), fax (541-322-7467), Email (livingwellinfo@dschts.org) and Web site URL (www.livewell.com.org). Below are spaces to write in the Client Name, Phone/Email, signature, date, and Provider Name. There is also a checkbox to agree to receive a call from the Oregon Tobacco Quitline and/or a Chronic Disease Self Management Program and a checklist to request weekly workshops: Live Well with Chronis Conditions, 'Tomando Control de Sa Salud' (the Spanish version), Positive Self Management Program (HIV), or personalized help from the Oregon Tobacco Quitline (1-800-QUIT-NOW, www.quitnow.net/oregon).
 


PLEASE COMPLETE FORM AND FAX OR MAIL TO

Living Well Central Oregon
Deschutes County Health Services
1234 NE Courtney Drive
Bend, OR 97000

FAX: 1-541-123-4567

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Publication:
14-0043-EF

Page last reviewed May 2014
Page originally created May 2014

Internet Citation: Tool 9.聽Sample Prescription Pad. Content last reviewed May 2014. 大象视频, Rockville, MD.
/ncepcr/tools/obesity/obpcp-tool9.html

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