Ophthalmology Order Form Physician Information Patient Information Order Date:

Ophthalmology Order Form
Pharmacy Creations — An Imprimis Pharmacy
Order Date:
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Date Medication To Be Administered:
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All formulas are customizable. If you need a medication not listed, please contact us. Phone: 866-792-7328 (toll-free)
Physician Information
Patient Information
Prescribing Physician:
Required
Patient Name:
DEA:
NPI#:
Birthdate:
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Center/Clinic:
Address 1:
Address 2:
City:
State:
Phone: (
)
Fax
Required
:(
Zip:
Patient Profile(s) or Block Schedule Attached: YES / NO (circle one)
)
# of Patients*:
Primary Contact:
*If multiple prescribing physicians, use separate order form for each.
Email:
Medication Orders
Medication
Strength or Concentration**, Form
Tri-Moxi
(Triamcinolone acetonide, moxifloxacin hydrochloride)
Tri-Moxi-Vanc
(Triamcinolone acetonide, moxifloxacin hydrochloride, vancomycin)
(15/1) mg/mL, injection
alternate__________________
(15/1/10) mg/mL, injection
alternate__________________
1:1000, injection
Lyophilized epinephrine
(1mg/mL reconstituted)
(1.5/1)%, injection
Phenylephrine + lidocaine
alternate__________________
(0.75/0.025)%, injection
Shugarcaine
(Lidocaine + epinephrine in BSS)
alternate__________________
Size/Volume
Quantity
Single-use vial
Single-use vial
Single-use vial
Single-use vial
Single-use vial
**Representative formulation. Customizable within certain ranges. Please contact the pharmacist to discuss.
Frozen preparation. Must ship overnight, will not ship out on Fridays.
! REMINDER: Please check patient information has been included for all medications before submitting
Order Submission
THIS FORM CONSTITUTES A PHYSICIAN’S ORDER/PRESCRIPTION WHEN SIGNED BY THE PHYSICIAN
Please Fax to Pharmacy Creations
540 Route 10 West
Randolph, NJ 07869
Fax: 855-405-4669 (toll-free)
Authorized Physician’s Signature
X
Please allow for 72-hours turnaround time (3 business days). Order by Weds. @ 12pm EST for deliveries by Friday
Payment Information
Credit Card Number:
Expiration:
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Security Code:
Billing Zip:
Current as of 10/18/14 v1.7