Transdermal Scar & Pain Topical Prescription This is a generic prescription and may be filled at any compounding pharmacy of your choice Patient Name:______________________________________ Gender: M / F DOB:______/______/________ Best Contact #:___________________________ Alternate #:_________________________________ Address:_____________________________________________ Diagnosis:_____________________ City:___________________ Email:___________________________________________________________ State:______ Zip:__________ ICD-9/10 Code:______________________ Allergies:____________________________________________________________________________ Last 4 of SS#:_________________ This prescription MUST include front and back of: Patient's Insurance card & Patient Demographic Sheet Intended uses, not indications; Commonly Prescribed Compounded Transdermal Medications for Pain & Scar Management GENERAL PAIN/INFLAMMATION MUSCULOSKETAL/NEUROPATHIC ARTHRITIC/NEUROPATHIC PAIN MuscuMed - 20 MuscuMed - 5 NeuraMed - 20 Flurbiprofen NEUROPATHIC/CHRONIC PAIN NeuraMed - 10 20% Flurbiprofen 5% Flurbiprofen 20% Flurbiprofen 10% Tramadol 5% Gabapentin 10% 6% Gabapentin 6% Clonidine 0.2% Bupivacaine 1% Gabapentin Lidocaine 5% Lidocaine 3% Cyclobenzaprine 4% Acyclovir 4% Cyclobenzaprine 2% Clonidine 0.2% Bupivacaine 3% Amitriptyline 2% Baclofen 4% Nifedipine 7% Deoxy-D-Glucose 2% Pentoxifylline 5% SCAR w/ STEROHIST SCAR MIGRAINE TRANSDERMAL GEL Scar w/ Sterohist Premium Scar Deluxe MTG Fluticasone 1% Levocetirizine- Fluticasone Propionate 1% Levocetirizine- -Dihydrochloride ** in silicone protective cream -Dihydrochloride 2% 2% Gabapentin NUMBING GEL Topical LBT Sumatripan 5% Benzocaine Bupivicane 2% Lidocaine 6% Pentoxifylline 5% Tetracaine 4% Naproxen 2% 20% 3% Prilocane 0.5% Pentoxifylline Additional Instructions: Qty: 30 grams 60 grams thirty sixty 120 grams 240 grams one hundred twenty two hundred forty 90 grams ninety Apply 1-3 pumps (1.5g/pump) to affected area 3-4 times a day as needed 360 grams three hundred sixty Refills: Dr. Phone: ( Office Address: City: DEA #: ) 1 2 - 3 Fax: ( State: 4 5 ) PRN Zip: NPI #: I, the undersigned, certify that the above prescribed compounded medication is medically necessary as part of my treatment for this patient. The medication prescribed is reasonable and necessary for accepted standards of medical practice and treatment of this patients condition and well being. Prescriber's Signature:_______________________________________________________ Date: , 2014 By signing this form I authorize the pharmacist to substitute alternate formulations to accommodate patient needs. (i.e. insurance restrictions, allergies, costs, etc.) PLEASE FILL OUT COMPLETELY & REMEMBER TO INCLUDE ALL ITEMS WHEN FAXING **** Please Note :This fax transmission contains information belonging to the sender and the recipient, which is legally confidential and privileged. If you are not the intended recipient you are hereby notified that any disclosure, copying, distribution, or taking any action in reliance on the contents of this faxed information is strictly prohibited.