Document 6538338

Podiatric - 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:______________________
Last 4 of SS#:_________________
LE
Allergies:____________________________________________________________________________
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
NEUROPATHIC/CHRONIC PAIN
MuscuMed - 20
MuscuMed - 5
NeuraMed - 20
NeuraMed - 10
Flurbiprofen
20%
Flurbiprofen
Tramadol
5%
Gabapentin
Clonidine
0.2%
Bupivacaine
Cyclobenzaprine
4%
Acyclovir
Bupivacaine
3%
Amitriptyline
Deoxy-D-Glucose
Flurbiprofen
20%
Flurbiprofen
6%
Gabapentin
6%
1%
Gabapentin
Lidocaine
5%
Lidocaine
3%
4%
Cyclobenzaprine
2%
Clonidine
0.2%
2%
Baclofen
4%
Nifedipine
7%
Pentoxifylline
5%
2%
SCAR
MIGRAINE TRANSDERMAL GEL
SA
MP
SCAR w/ STEROHIST
5%
10%
PC - 5
Premium Scar Deluxe
1%
Fluticasone
Levocetirizine-
Fluticasone Propionate
Levocetirizine-
-Dihydrochloride
2%
-Dihydrochloride
Prilocane
GOUT
Vancomycin
5%
Bupivicane
2%
Mupirocin
5%
Pentoxifylline
5%
Naproxen
2%
0.5%
ANTI-INFECTIONAL
Anti-Fungal/Wound
Flurbiprofen
10%
Bupivacaine
2%
0.2%
5%
Urea
Itraconazole
5%
Itraconazole
0.1%
60 grams
thirty
sixty
120 grams
240 grams
one hundred twenty
two hundred forty
90 grams
ninety
0.05%
Betamethasone
Mupirocin
30 grams
WOUND
Anti-Infectional
20%
Urea
Fluticasone
Qty:
5%
ANTI-FUNGAL/WOUND
Gout
Wound
Sumatripan
3%
Pentoxifylline
Colchine
2%
Gabapentin
** in silicone protective cream
WOUND
MTG
1%
10%
Wound
2.5%
Vancomycin
20%
Levofloxcin
1%
2%
Clindamycin
1%
0.77%
Ciclopirox
Apply 1-3 pumps (1.5g/pump) to affected area 3-4 times a day
as needed
360 grams
Refills:
three hundred sixty
1
2
3
4
5
PRN
Additional Instructions:____________________________________________________________________________________________
Dr.
Phone: (
Office Address:
City:
DEA #:
)
-
Fax: (
State:
)
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.