Multi-Purpose Wound & Scar Care Fax To:_____________________ PLEASE WRITE CLEARLY AND ATTACH PATIENT FACT SHEET. Physician Patient D.O.B. Mobile Home Address Address City State Phone NPI Zip City State Fax Rx. Ins ID # DEA Group BIN Allergies FIRST ORDER: PLEASE FAX CURRENT PRESCRIPTION INSURANCE. Soy (Some cream bases may contain soy) Zip SSN Other PRESCRIPTION SCAR GEL MULTIPURPOSE TOPICAL SCAR GEL Note: This scar gel therapy compounded using PracaSil™-Plus as a base Topical gel for new and older scars with or without pain, inflammation and/or itching New Scars Keloids and h ypertrophic Scars Fluticasone Propionate 1% /Levocetirizine Dihydrochloride 2% /Pentoxifyline USP 0.5% /PrilocaineHCI 3% / Gabapentin USP 15% Tamoxifen Citrate 0.1% /Tranilast 1% / Caffeine Citrated 0.1% /Lipoic Acid 0.5% Topical Gel Pentoxifylline 0.3% /Caffeine 1% /EGCg 1% Topical Gel Gabapentin 15% /Lidocaine HCI 3% /Prilocaine HCI 3% Topical Gel Betamethasone Valerate 0.1% /Tranilast 1% Pentoxifylline 0.5% Topical Gel Painful Scars Gabapentin 15% /Lidocaine HCI 3% / Prilocaine HCI 3% Topical Gel Stretch Marks / Pregnancy Post Surgical Scars / New Scars Collagenase 350 U/Gm/Hyaluronidase 250 U/gm Compound Topical Gel Betamethasone Valerate 0.1% /Tranilast 1% Topical Gel Scar Prevention Acne Scars EGCg 1% /Dimethyl Sulfone 2% /Tranilast 1% /Ascorbic Acid 2% Topical Gel EGCg 1% /Dimethyl Sulfone 5% /Ascorbic Acid 2% /Caffeine 1% Topical Gel Tretinoin 0.1% Topical Gel Tretinoin 0.1% Topical Gel 480 gm Other:_________ 120 gm 240 gm Check Quantity: 60 gm Check SIG: Apply 2-4 pumps topically TWICE daily to healed incisions/scars as directed (1 GRAM PER PUMP) Other ______________________ PRESCRIPTION WOUND CARE TOPICAL WOUND CARE TREATMENT Venous Ulcers, Pressure Ulcers, Diabetic Ulcers, etc Prescriber please NOTE: Due to risk of renal toxicity, do NOT prescribe polyethylene glycol (PEG) containing compounds for treatment of wounds covering more then 20% of body. DO NOT PRESCRIBE FORMULATIONS CONTAINING MISOPROSTOL TO A PREGNANT AND / OR BREASTFEEDING FEMALE. Use caution in women of childbearing age. Formulations are topical compounds applied directly to wound and/or dressing. Mupirocin 5% / Itraconazole 5% / Fluticasone Propionate 1% / Urea 40% Spira-Wash™ Gel Phenytoin 5% / Misoprostol 0.0024% / Nifedipine 2% Spira-Wash™ Gel Misoprostol 0.0024% / Metronidazole 2% / Lidocaine HCI 2% Spira-Wash™ Gel Levofloxacin 2% / Mupirocin 4% / Itraconazole 1% Spira-Wash™ Gel Vancomycin 5% / Mupirocin 5% Spira-Wash™ Gel Check to Add to Formulation: Antibiotics / Antifungal Pain / Inflammation Metronidazole 2% Mupirocin 5% Clindamycin HCI USP 1% Polymixin B 2000 Units/gm Ketoprofen 2% Prilocaine HCI 2% 480 gm 240 gm Check Quantity: 120 gm Check SIG: Apply 1-2 pumps (1-2gm) TOPICALLY to wound FREQUENCY: BID Vancomycin 5% Itraconazole 1% Levofloxacin 2% Other ____________ Other:____________ Apply 2-4 pumps (2-4gm) TOPICALLY to wound Other ___________________________________________________ For your convenience, we will auto-refill this prescription Refills for Topical Scar Gel /Wound Cream: (circle one) 1 2 3 4 5 Other_________________ unless otherwise indicated. Physician Signature Date Rep ID:_______________