FAX TO 941-827-7315 HIGHLY CONFIDENTIAL TRADE SECRET Compounding Pharmacy PATIENTS NAME: DOB: ADDRESS: APT: ALTERNATE CONTACT #: PRIMARY CONTACT #: ZIP: STATE: ALLERGIES: INSURANCE CARRIER: (OR YOU MAY PROVIDE A COPY OF THE PATIENT’S CARD – FRONT & BACK) ID#: PHONE#: Rx Group#: BIN#: DOCTOR NAME: ADDRESS: PHONE #: DEA: FAX: NPI: LEGAL NOTE: This Fax transmission may contain confidential information belonging to the sender, which is legally privileged. This information is intended only for the use of the recipient named above. If you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution, or taking of any action in reliance of the contents of this faxed information is strictly prohibited. Please notify us by phone to arrange for the return of the original documents. I have reviewed my patient’s medical record(s) and determine that the items that I have ordered are medically necessary. I verify that I had a face to face examination with the above patient. I agree to comply with state and federal documentation requirements be retaining a copy of this prescription in the patient’s medical records. The prescription is to be dispensed as written unless otherwise instructed. ❑ LABEL RX IN SPANISH PATIENT DIAGNOSIS: PAIN MANAGEMENT PAIN RELIEF FOR MUSCLES - TENDONS - LIGAMENTS - JOINTS - BONES -STIFFNESS - INFLAMMATION - MUSCLE SPASMS ❑ Cyclobenzaprine 2% Flurbiprofen 15% FCGL Anti-Inflammatory Gabapentin 10% Muscle Relaxant Lidocaine 5% Anesthetic Neuropathy ARTHRITIS - TENDONITIS - OSTEOARTHRITIS - RHEUMATISM INFLAMMATION - SWELLING ❑ Flurbiprofen 20% Baclofen 4% FBCGB Anti-Inflammatory Anti-Spastic Cyclobenzaprine 2% Gabapentin 10% Bupivicaine 3% Neuropathy Muscle Relaxant Anesthetic MIGRAINE ❑ Pentoxifylline 5% Sumatriptan 5% MIG-2 Serotonin Receptor Agonist Dexamethasone 0.1% Anti- Inflammatory Increases Blood Flow PAIN RELIEF PATCHES ❑ Menthol 5% ❑ 60 Patches Lidocaine 4% Lidocaine 5% Anesthetic SIG : Apply 1 patch to affected area 1 to 2 times daily (#60) SIG : Apply 1 to 2 patches to affected area twice daily (#120) ❑ 120 Patches OTHER FORMULATIONS GENERAL WELLNESS SUPPLEMENT ❑ GW Coenzyme Q-10 100mg - Lipoic Acid 250 mg - Vitamin D3 1000 IU - Methylcobalamin 10 mg Pyridoxial- 5-Phosphate 70 mg - Resveratrol 100mg - Folic Acid 1mg - NADH 5 mg-Oral Capsule BRUISE REDUCTION ❑ BRG1 Arnica 1% Sig: Apply 1-2 grams to affected area 2-3 times a day Phytonadione 2% WOUND AND SCAR CARE ❑ DPPGH Dephinhydramine 2% Anti-Itch Vitamin E 5 IU/GM Pentoxifylline 0.5% Reduces Collagen Production Hyaluronic Acid 0.1% Green Tea 0.5% Prilocaine 3% Gabapentin 15% Hydrocortisone 3% Anesthetic Neuropathy Anti-Itch ANTIFUNGAL ❑ MIFU Mupirocin 5% Itraconazol 5% Antibioti Anti-Fungal Fluticasone 1% Anti-Inflammatory Urea 40% Absorbtion Agent ANTI-ANXIETY ❑ APO Apomorphine 0.2% Sig: Apply 1-2 grams 2-3 times daily to the back of the hair-line Oxytocin .06% ❑ 180 GM ❑ 360 GM OTHER FORMULATION OR CHANGES: Note: Please cross out any unwanted medication in above formulations Note: Ketamine is controlled Schedule III, substitute Amantadine 8% if desired QUANTITY: ❑ 240 GM ❑ 360 GM ❑ 60 Capsules SIG : Apply 1 to 2 grams to affected area 3 to 4 times daily SIG : Take one tablet by mouth twice daily DOCTOR'S SIGNATURE : REFILLS: (CIRCLE ONE) 1 2 3 4 5 AUTO REFILL ❑ ❑ If insurance denies the pain cream and the patch, substitute 10% Ibuprofen and 5% Lidocaine. DATE :