Document 6481104

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.