1. No category

Faxed prescriptions will only be accepted from a prescribing practitioner.
Patients must bring an original prescription to the pharmacy.
Prescription Referral Form
2829 Babcock Road, Suite # 120 • San Antonio- 78229, TX • Ph : 210.617. 4311 • Fax: 210.617. 4312
www.GalaxySpecialtyPharmacy.com
(Christus SantaRosa Hospital, Tower # 1)
Date Medication Needed:
Ship To:
Patient’s Home
Injection training
by pharmacy?
Prescriber’s
1: Patient Information
Patient Name:
Birthdate:
Soc. Sec. #:
Preferred Phone:
Address:
Sex:
Male
Female
Height:
lbs.
kg.
Known Allergies:
City:
Alternate Caregiver Name:
Weight:
State:
Zip:
Preferred Phone:
Insurance Information: Please fax FRONT and BACK copy of ALL Insurance cards (Prescription and Medical)
2: Prescriber Information
Provider Name:
DEA#:
Address:
Phone:
NPI#:
Fax:
Tax ID#:
City, State, Zip:
Key Contact:
Phone:
3: Prescription Information
%
1%
0.2%
5%
6%
Bupivacaine
Clonidine
Doxepin
Gabapentin
Sig.
Amantadine
Bupivacaine
Diltiazem
Doxepin
Gabapentin
Orphenadrine
Topiramate
Sig.
NR
Ketoprofen
Ibuprofen
Cylcobenzaprine
Piroxicam
Lidocaine
10%
10%
2%
2%
2%
Sig.
NR
Quantity
NR
Quantity
Quantity
%
1%
3%
6%
6%
1%
Bupivacaine
Carbamazeipine
Doxepin
Gabapentin
Topiramate
Sig.
%
1%
3%
6%
0.5%
5%
Bupaivacaine
Doxepin
Gabapentin
Ketorolac
Ayclovir
Sig.
NR
NR
Quantity
%
1%
3%
3%
6%
5%
Sig.
%
2%
1%
2%
6%
5%
Baclofen
Bupivacaine
Cylcobenzaprine
Gabapentin
Orphenadrine
%
1%
3%
6%
2%
Bupivacaine
Doxepin
Gabapentin
Nifedipine
Sig.
NR
Quantity
Diclofenac
Baclofen
Bupivacaine
Ibuprofen
Quantity
Bupivacaine
Diclofenac
Doxepin
Gabapentin
Orphenadrine
3%
2%
1%
3%
Sig.
NR
Quantity
Other
Sig.
Sig.
NR
Quantity
8%
1%
2%
3%
6%
5%
2%
NR
Quantity
NR
Quantity
Prescriber Signature: Prescriber, please sign and date below
Dispense as written
Date
IMPORTANT NOTICE:
Pursuant to VA/OH/MO/VT law, only 1 medication is permitted per order form. Please use a new form for additional items.
Substitution Permissable
Date
# of Prescriptions: ______________