Multi-Purpose Wound & Scar Care PRESCRIPTION SCAR GEL New Scars

Multi-Purpose Wound & Scar Care
Fax To:_____________________
PLEASE WRITE CLEARLY AND ATTACH PATIENT FACT SHEET.
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FIRST ORDER: PLEASE FAX CURRENT PRESCRIPTION INSURANCE.
Soy
(Some cream bases
may contain soy)
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PRESCRIPTION SCAR GEL
MULTIPURPOSE TOPICAL SCAR GEL
Note: This scar gel therapy compounded
using PracaSil™-Plus as a base
Topical gel for new and older scars with or without pain, inflammation and/or itching
New Scars
Keloids and h ypertrophic Scars
Fluticasone Propionate 1% /Levocetirizine
Dihydrochloride 2% /Pentoxifyline USP 0.5%
/PrilocaineHCI 3% / Gabapentin USP 15%
Tamoxifen Citrate 0.1% /Tranilast 1% / Caffeine
Citrated 0.1% /Lipoic Acid 0.5% Topical Gel
Pentoxifylline 0.3% /Caffeine 1%
/EGCg 1% Topical Gel
Gabapentin 15% /Lidocaine HCI 3%
/Prilocaine HCI 3% Topical Gel
Betamethasone Valerate 0.1% /Tranilast 1%
Pentoxifylline 0.5% Topical Gel
Painful Scars
Gabapentin 15% /Lidocaine HCI 3% /
Prilocaine HCI 3% Topical Gel
Stretch Marks / Pregnancy
Post Surgical Scars / New Scars
Collagenase 350 U/Gm/Hyaluronidase 250 U/gm
Compound Topical Gel
Betamethasone Valerate 0.1% /Tranilast 1%
Topical Gel
Scar Prevention
Acne Scars
EGCg 1% /Dimethyl Sulfone 2% /Tranilast 1%
/Ascorbic Acid 2% Topical Gel
EGCg 1% /Dimethyl Sulfone 5% /Ascorbic Acid
2% /Caffeine 1% Topical Gel
Tretinoin 0.1% Topical Gel
Tretinoin 0.1% Topical Gel
480 gm
Other:_________
120 gm
240 gm
Check Quantity:
60 gm
Check SIG: Apply 2-4 pumps topically TWICE daily to healed incisions/scars as directed (1 GRAM PER PUMP)
Other ______________________
PRESCRIPTION WOUND CARE
TOPICAL WOUND CARE TREATMENT
Venous Ulcers, Pressure Ulcers, Diabetic Ulcers, etc
Prescriber please NOTE: Due to risk of renal toxicity, do NOT prescribe polyethylene glycol
(PEG) containing compounds for treatment of wounds covering more then 20% of body. DO
NOT PRESCRIBE FORMULATIONS CONTAINING MISOPROSTOL TO A PREGNANT AND /
OR BREASTFEEDING FEMALE. Use caution in women of childbearing age. Formulations are
topical compounds applied directly to wound and/or dressing.
Mupirocin 5% / Itraconazole 5% / Fluticasone Propionate 1% / Urea 40% Spira-Wash™ Gel
Phenytoin 5% / Misoprostol 0.0024% / Nifedipine 2% Spira-Wash™ Gel
Misoprostol 0.0024% / Metronidazole 2% / Lidocaine HCI 2% Spira-Wash™ Gel
Levofloxacin 2% / Mupirocin 4% / Itraconazole 1% Spira-Wash™ Gel
Vancomycin 5% / Mupirocin 5% Spira-Wash™ Gel
Check to Add to Formulation:
Antibiotics / Antifungal
Pain / Inflammation
Metronidazole 2%
Mupirocin 5%
Clindamycin HCI USP 1%
Polymixin B 2000 Units/gm
Ketoprofen 2%
Prilocaine HCI 2%
480 gm
240 gm
Check Quantity:
120 gm
Check SIG:
Apply 1-2 pumps (1-2gm) TOPICALLY to wound
FREQUENCY:
BID
Vancomycin 5%
Itraconazole 1%
Levofloxacin 2%
Other ____________
Other:____________
Apply 2-4 pumps (2-4gm) TOPICALLY to wound
Other ___________________________________________________
For your convenience, we will
auto-refill this prescription
Refills for Topical Scar Gel /Wound Cream: (circle one) 1 2 3 4 5 Other_________________
unless otherwise indicated.
Physician Signature
Date
Rep ID:_______________