Note: This form is intended for prescriber use only. If faxed, the fax must come from MD office or hospital (should not be faxed by patient).
rd
3 Party Pharmacy Services Prescription Form
Center Name:
Address:
City, State and Zip:
Phone:
Fax:
Bill to:
Today’s Date: _____________ Ordered By: _____________________________________________Needs By Date (REQUIRED): ______________________
Recipient
Donor (
KNOWN
ANONYMOUS)
Carrier
Name: _________________________________________ DOB: ______________ ICD-9: ____________
NKDA
Allergies _____________________________________
For recipient please include contact numbers. Indicate priority with a number 1, 2 and 3 in check box.
Home: _________________________________
Donor (
KNOWN
ANONYMOUS)
Work: ______________________________________
Carrier
Donor ID/Name: ________________________________ DOB: ______________ ICD-9: ____________
Ship to:
DONOR
Donor
Clinic
Cell: _____________________________________
Carrier
NKDA
Allergies _____________________________________
Other _______________ Ship to Address: _____________________________________________________________________
RECIPIENT
CARRIER
RECIPIENT
Desogen
Other: __________________________
Sig.: _____________________________ (= ___ days)
____ Qty (Packs)
____ Refills
Desogen
Other: ___________________________
Sig.: ______________________________ (= ___ days)
____ Qty (Packs)
____ Refills
leuprolide acetate 1mg/0.2ml – 2 Week Kit
Sig.: _____________________________ (= ___ days)
____ Qty (Kits)
____ Refills
leuprolide acetate 1mg/0.2ml – 2 Week Kit
Sig.: _____________________________ (= ___ days)
____ Qty (Kits)
____ Refills
Microdose leuprolide acetate ______mcg/______ml
½ml Insulin Syringes #____
Sig.: ________________________________ (= ___ days)
10ml Vial
____Qty (Vials)
____ Refills
Lupron Depot ______________ mg
Sig.: ________________________________ (= ___ days)
____ Qty (Each)
____ Refills
Estrace 1mg
2mg
Sig.: ________________________________ (= ___ days)
____ Qty (Tabs)
____ Refills
Vivelle-Dot 0.1mg
Sig.: ________________________________ (= ___ days)
____ Qty (Patches)
____ Refills
Medrol _____mg
Sig.: ________________________________ (= ___ days)
____ Qty (Tabs)
____ Refills
leuprolide
2 MG PFS-40 Unit
4 MG PFS-80 Unit
Sig.: _____________________________ (= ___ days)
___ PFS
____Refills
Lupron Depot ______________ mg
Sig.: ________________________________ (= ___ days)
____ Qty
____ Refills
Ganirelix Acetate for Injection 250mcg
Sig.: _______________________________ (= ___ days)
____ Qty
____ Refills
Cetrotide 0.25mg
Sig.: ________________________________ (= ___ days)
____ Qty (Kits)
____ Refills
Follistim AQ Cartridge
Follistim Pen
QTY: ____ 300 ____ 600 ____ 900 International Units
Sig.: ________________________________ (= ___ days)
____ Refills
Gonal-f RFF Pen
Qty: ____ 300 ____ 450 ____ 900 International Units
Gonal-f RFF Redi-ject
Qty: ____ 300 ____ 450 ____ 900 International Units
Sig.: ________________________________ (= ___ days)
____ Refills
Gonal-f
450
1050 International Units Multidose
Gonal-f RFF 75 International Units
Sig.: ________________________________ (= ___ days)
____ Qty (Vials)
____ Qty (Vials)
____ Refills
Bravelle 75 International Units
IM
SC
____ Qty (Vials)
Menopur 75 International Units
IM
SC
____ Qty (Vials)
#___ 3ml 22g 1 ½” syringes/needles #___ ___g ___” needles
Sig.: ________________________________ (= ___ days) ____ Refills
HCG 10,000 International Units
____ Qty (Vials)
Novarel 10,000 International Units
DAW
____ Qty (Vials)
Pregnyl 10,000 International Units
DAW
____ Qty (Vials)
#___ 3ml 22g 1 ½” syringes/needles #___ ___g ___” needles
Sig.: ________________________________ (= ___ days) ____ Refills
Ovidrel 250mcg Prefilled Syringes
Sig.: ________________________________ (= ___ days)
____ Qty (PFS)
____ Refills
Other:
Sig.: ________________________________ (= ___ days)
____ Qty
____ Refills
Progesterone in Sesame Oil 50mg/ml 10ml Vial
____ Qty (Vials)
#____ 3 cc 18g 1½ ” needle
#____ 22 g 1½ ” needle
Sig.: ________________________________ (= ___ days) ____ Refills
Progesterone Vag Suppository _____ mg
Sig.: ________________________________ (= ___ days)
____ Qty (Supps)
____ Refills
Prometrium _____mg
DAW
Sig.: ________________________________ (= ___ days)
____ Qty (Caps)
____ Refills
Compounded Progesterone
50mg
300mg
400mg
____ Qty (Caps)
Sig.: _____________________________ (= ___ days) ____ Refills
Endometrin Vaginal Tablet 100mg
Sig.: ________________________________ (= ___ days)
____ Qty (Tabs)
____ Refills
Crinone 8% Gel – 15 per box
Sig.: ________________________________ (= ___ days)
____ Qty (Apps)
____ Refills
Doxycycline 100mg
Sig.: ________________________________ (= ___ days)
____ Qty (Caps)
____ Refills
Doxycycline 100mg
____ Qty (Caps)
Partner’s Name: ____________________________________
Sig.: ________________________________ (= ___ days) ____ Refills
Other:
Sig.: ________________________________ (= ___ days)
____ Qty
____ Refill
Other:
Sig.: ________________________________ (= ___ days)
____ Qty
____ Refill
Prescriber’s Signature: _______________________________________________________________________________ MD
DEA#_____________________
INTERCHANGE IS MANDATED UNLESS PRACTITIONER WRITES THE WORDS “BRAND NAME NECESSARY” IN THIS SPACE
Prescriber’s Name (Print): ____________________________________________________________________________
CONFIDENTIAL HEALTH INFORMATION: Healthcare information is personal information related to a person’s healthcare. It is being faxed to you after appropriate authorization or under circumstances that don’t require
authorization. You are obligated to maintain it in a safe, secure, and confidential manner. Re-disclosure of this information is prohibited unless permitted by law or appropriate customer/patient authorization is obtained.
Unauthorized re-disclosure or failure to maintain confidentiality could subject you to penalties described in federal and state laws.
Drug names are the property of their respective owners.
©2014 Walgreen Co. All rights reserved.
0114HDS
Frisco, TX
Donor Phone: 888-388-8933
Donor Fax: 866-405-2395