Order Form + Cover Sheet

Fax
To:
Pharmacy Creations
Fax:
855-405-4669
From:
Phone: 866-792-7328
Fax:
Phone:
Number of Pages:
Date:
Comments:
■
PROTECTED HEALTH INFORMATION
BUSINESS CONFIDENTIAL INFORMATION
This fax is intended only for the exclusive use of the addressee(s), and may contain privileged or confidential
information. If you are not the intended recepient, or the person responsible for delivering the fax to the intended
recepient, be advised you have received this fax in error and that use, dissemination, distribution, or copying of this
communication is strictly prohibited. If you have received this fax in error, please destroy the attached document(s)
and immediately notify the sender of the error.
Please deliver to:
Order Fulfillment
with this cover sheet to protect its contents.
Ophthalmology Order Form - TOPICAL
Order Date:
PHARMACY CREATIONS
Randolph, New Jersey
An Imprimis Pharmacy
/
Phone: 866-792-7328 (toll-free)
Earliest Date To Be Administered:
/
/
/
Please allow for 72-hours turnaround time (3 business days) before order will ship. Incomplete order submissions may delay processing.
Physician Information
Required
Prescribing Physician:
Patient Information
Required
Patient Name:
DEA:
NPI#:
Birthdate:
/
Phone: (
/
)
Address:
Center/Clinic:
Address:
Known Drug Allergies:
City:
State:
Phone: (
)
Fax: (
Zip:
No Known Drug Allergies (NKDA)
)
Primary Contact:
Patient Profile(s) or Block Schedule Attached:
Email:
# of Patients*:
*If multiple prescribing physicians, use separate order form for each.
Medication Orders
Paid by:
Physician/Clinic
Patient
Ship to:
Physician/Clinic
Patient
YES
NO (circle one)
If you need a medication not listed, please contact us at 866-792-7328 (toll-free)
Medication
Strength or Concentration
Pred-Moxi
(Prednisolone acetate and moxifloxacin
hydrochloride)
1**
alternate__________________
Pred-Ketor
(Prednisolone acetate and ketorolac
tromethamine)
**
alternate__________________
Pred-Moxi-Ketor
(Prednisolone acetate, moxifloxacin
hydrochloride, and ketorolac tromethamine)
Tri-Moxi
(Triamcinolone acetonide and moxifloxacin
hydrochloride)
**
alternate__________________
**
alternate__________________
Size/Volume
Instructions for use
3mL
dropper
Instill into the affected eye(s)
following the instructions provided
by your prescriber
3mL or 6mL
dropper
Instill into the affected eye(s)
following the instructions provided
by your prescriber
mL
dropper
Instill into the affected eye(s)
following the instructions provided
by your prescriber
mL
dropper
Instill into the affected eye(s)
following the instructions provided
by your prescriber
Quantity
# Refills
_ that state law allows patients to receive medications from a pharmacy of their choice
*Prescribers are reminded
**Representative formulation. Customizable within certain ranges. Please contact the pharmacist to discuss.
! 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 with cover sheet to Pharmacy Creations
855-405-4669
Authorized Physician’s Signature
X
Please allow for 72-hours turnaround time (3 business days) before order will ship. Incomplete order submissions may delay processing.
# of Prescriptions
Payment Information
IF YOU ARE NOT CURRENTLY BEING INVOICED, PLEASE SUBMIT THE FOLLOWING:
Credit Card Number:
Expiration:
CVC Code:
This form is provided in an effort to improve patient safety.
Pursuant to VA/OH/MO/VT law, only 1 medication is permitted per order form. Please use a new form for additional items.
Billing Zip:
Current as of 4/14/15 v1
Patient Information
First & Last Name
Birthdate
Address
Phone Number
Known Drug Allergies
NKDA
Ship to Patient
Ship to Clinic
First & Last Name
Number of Refills:
Birthdate
Paid by:
Address
Phone Number
Physician/Clinic
Patient
Known Drug Allergies
NKDA
Ship to Patient
Ship to Clinic
First & Last Name
Number of Refills:
Birthdate
Paid by:
Address
Phone Number
Physician/Clinic
Patient
Known Drug Allergies
NKDA
Ship to Patient
Ship to Clinic
First & Last Name
Number of Refills:
Birthdate
Paid by:
Address
Phone Number
Physician/Clinic
Patient
Known Drug Allergies
NKDA
Ship to Patient
Ship to Clinic
First & Last Name
Number of Refills:
Birthdate
Paid by:
Address
Phone Number
Physician/Clinic
Patient
Known Drug Allergies
NKDA
Ship to Patient
Ship to Clinic
First & Last Name
Number of Refills:
Birthdate
Paid by:
Address
Phone Number
Physician/Clinic
Patient
Known Drug Allergies
NKDA
Ship to Patient
Ship to Clinic
First & Last Name
Number of Refills:
Birthdate
Paid by:
Address
Phone Number
Physician/Clinic
Patient
Known Drug Allergies
NKDA
Ship to Patient
Ship to Clinic
Number of Refills:
Paid by:
Physician/Clinic
Patient