Podiatric - 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:______________________ Last 4 of SS#:_________________ LE Allergies:____________________________________________________________________________ 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 NEUROPATHIC/CHRONIC PAIN MuscuMed - 20 MuscuMed - 5 NeuraMed - 20 NeuraMed - 10 Flurbiprofen 20% Flurbiprofen Tramadol 5% Gabapentin Clonidine 0.2% Bupivacaine Cyclobenzaprine 4% Acyclovir Bupivacaine 3% Amitriptyline Deoxy-D-Glucose Flurbiprofen 20% Flurbiprofen 6% Gabapentin 6% 1% Gabapentin Lidocaine 5% Lidocaine 3% 4% Cyclobenzaprine 2% Clonidine 0.2% 2% Baclofen 4% Nifedipine 7% Pentoxifylline 5% 2% SCAR MIGRAINE TRANSDERMAL GEL SA MP SCAR w/ STEROHIST 5% 10% PC - 5 Premium Scar Deluxe 1% Fluticasone Levocetirizine- Fluticasone Propionate Levocetirizine- -Dihydrochloride 2% -Dihydrochloride Prilocane GOUT Vancomycin 5% Bupivicane 2% Mupirocin 5% Pentoxifylline 5% Naproxen 2% 0.5% ANTI-INFECTIONAL Anti-Fungal/Wound Flurbiprofen 10% Bupivacaine 2% 0.2% 5% Urea Itraconazole 5% Itraconazole 0.1% 60 grams thirty sixty 120 grams 240 grams one hundred twenty two hundred forty 90 grams ninety 0.05% Betamethasone Mupirocin 30 grams WOUND Anti-Infectional 20% Urea Fluticasone Qty: 5% ANTI-FUNGAL/WOUND Gout Wound Sumatripan 3% Pentoxifylline Colchine 2% Gabapentin ** in silicone protective cream WOUND MTG 1% 10% Wound 2.5% Vancomycin 20% Levofloxcin 1% 2% Clindamycin 1% 0.77% Ciclopirox Apply 1-3 pumps (1.5g/pump) to aﬀected area 3-4 times a day as needed 360 grams Reﬁlls: three hundred sixty 1 2 3 4 5 PRN Additional Instructions:____________________________________________________________________________________________ Dr. Phone: ( Oﬃce Address: City: DEA #: ) - Fax: ( State: ) 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.