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Tion Signature of Nurse Receiving Medication Pharmacist Name Date DISPOSITION OF REMAINING DOSES - Per Facility Policy Quantity Doses transferred to a medical waste container Doses flushed Date Nurse Signature OPTIONAL BOX FOR LABEL Doses incinerated Doses mixed with cat litter/ coffee grounds Other: Date Doses Transferred to other Disposal Record Doses Discharged with Resident Witness Signature Title Signature Title Quantity Date DATE TIME AMT. ON HAND.

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