DATE (mm/dd/yy)
/ / / / / / / / / / / / / / / / / / / / /
DRUG NAME
DOSE
FORM (tab, etc.)
COUNT (#)
/ / / / / / / / / / / / / / / / / / / / /
REASON CODES*
TE
Name
D A
T TI EN PA
Medication Destruction Record
DOB
REASON* (circle)
DESTROYER (signature)
12345 12345 12345 12345 12345 12345 12345 12345 12345 12345 12345 12345 12345 12345 12345 12345 12345 12345 12345 12345 12345 1 2
Med discontinued by provider Patient experienced adverse reaction
3 4 5
Patient deceased Patient discharged Other
Month Year
WITNESS 1 (signature)