oncology

Phone: (877) 868-4110 Fax: (877) 868-4144

Prescribers and Staff

YOUR ONE-STOP SOLUTION

Our goal is to service all of the needs of your office and your patients.

• A member of our team will fax prescription and patient status updates throughout the prescription process• Prior authorizations to initiate treatment• Re-Authorization to prevent therapy interruption• Cost management•• No cost for delivery to patient home or your office• Injection training for self injectable medications at patient home or in your office• Disease and treatment education prior to therapy initiation• Ongoing side effects management• Customize patient monitoring• Refill reminders and coordination•• Retail prescriptions to ensure patients have ONE PHARMACY• Infusion & Compounding services available

AMERICAN SPECIALTY PHARMACY is able to assist you. We are a SpecialtyPharmacy with retail stores with the ability to fill ALL of your patient’s medications.

Attached you will find a Prescription Referral Form for use with specific chronicillnesses. If your patients also need other medications not listed, just send the

prescription along with it and we’ll take care of that too!

For more information please call or email:

Phone: (877) 868-4110 | Fax: (888) 294-9434 | Email: [email protected]

PLANO,TX | DENTON, TX | SAN ANTONIO | EL PASO, TX | TYLER, TX

www.AMERICANSPECIALTYPHARMACY.com

BACLOFEN Strengths Up to 20cc 21 to 30cc 31 to 60cc up to 1000mcg/ml 1001mcg/nl up to 2000mcg/ml 2001mcg/ml up to 4000mcg/ml

BUPIVACAINE Strengths Up to 20cc 21 to 30cc 31 to 60cc up to 8mg/ml (.8%) 8.1mg/ml up to 40mgml (4%)

CLONIDINE Strengths Up to 20cc 21 to 30cc 31 to 60cc up to 2000mcg/ml 2001mcg/ml to 4000mcg/ml

DROPERIDOL Strengths Up to 20cc 21 to 30cc 31 to 60cc up to 20mcg/ml 21mcg/ml and up

FENTANYL Strengths Up to 20cc 21 to 30cc 31 to 60cc up to 50mcg/ml 51mcg/ml up to 500mcg/ml 501mcg/ml up to 1000mcg/ml 1001mcg/ml up to 3000mcg/ml 3001mcg/ml up to 5000mcg/ml 5001mcg/ml up to 7500mcg/ml 7501mcg/ml up to 10,000mcg/ml 10,001mcg/ml up to 15,000mcg/ml 15,001mcg/ml up to 20,000mcg/ml 20,001mcg/ml up to 25,000mcg/ml

HYDROMORPHONE Strengths Up to 20cc 21 to 30cc 31 to 60cc up to 15mg/ml 15.1mg/ml up to 30mg/ml 30.1mg/ml up to 45mg/ml 45.1mg/ml up to 60mg/ml 60.1mg/ml up to 80mg/ml 80.1mg/ml up to 90mg/ml 90.1mg/ml up to 150mg/ml

KETAMINE Strengths Up to 20cc 21 to 30cc 31 to 60cc up to 20mcg/ml 21mcg/ml and up

MEPERIDINE Strengths Up to 20cc 21 to 30cc 31 to 60cc up to 50mg/ml 50.1mg/ml up to 100mg/ml 100.1mg/ml up to 200mg/ml

METHADONE Strengths Up to 20cc 21 to 30cc 31 to 60cc up to 25mg/ml 25.1mg/ml up to 50mg/ml 50.1mg/ml up to 80mg/ml

MORPHINE Strengths Up to 20cc 21 to 30cc 31 to 60cc up to 25mg/ml 25.1mg/ml up to 50mg/ml 50.1mg/ml up to 60mg/ml 60.1mg/ml up to 70mg/ml

ROPIVACAINE Strengths Up to 20cc 21 to 30cc 31 to 60cc up to 10mg/ml

PRIALT CALL FOR PRICING

SUFENTANIL Strengths Up to 20cc 21 to 30cc 31 to 60cc up to 50mcg/ml 51mcg/ml up to 100mcg/ml

TETRACAINE Strengths Up to 20cc 21 to 30cc 31 to 60cc up to 10mg/ml (1%) 10.1mg/ml up to 20mg/ml (2%)

INTRATHECAL MEDICATION LIST

FREE DELIVERY2743 W. 15th St., Plano, TX 75075

Ph: 877-868-4110 Fax: 877-868-4144

/GFKECVKQPUECPDGRTQXKFGFKPU[TKPIGUQTXKCNU8KCNUYKNNDGWUGFWPNGUUQVJGTYKUGURGEKƂGF 3WGUVKQPUQT%QPEGTPUECNN PLANO - DENTON - TYLER - SAN ANTONIO - EL PASO - MIAMI

OUR PRODUCTS & SERVICES We are a full service pharmacy that specializes in:

Compounded & Specialty MedicationsDurable Medical Equipment (DME)

Nutritional SupplementationWorkers’ Compensation Prescriptions

Everyday Prescriptions

WE TAKE THE BURDEN OFF OF YOUOur customer service is second to none; provided by highly trained sta . We assist each patient throughout the entire

process. From contacting your insurance carrier to automatic re lls and overnight delivery.

We look forward to serving you and meeting all of your pharmacy needs.


HOURS OF OPERATIONMon - Fri 9am until 7pm Sat & Sun 9am until 3pm

COMPLIMENTARY DELIVERYAll deliveries are delivered straight to

your door within 24 hours at no out-of-pocket cost to you.

AUTOMATIC REFILLSYour re lls are lled automatically based on

your prescription or physician’s approval. It is not necessary to reorder!

PLANO LOCATION2743 West 15th Street

Plano, TX 75075P: 877-868-4110 . F: 877-868-4144

[email protected]

At American Specialty Pharmacy, we use the latest technology with top quality ingredients to compound safe

and e ective customized medications. Our pharmacists are experts at compounding new, discontinued, back-ordered, or

unavailable medications to meet speci c patient needs.

We o er a full line of Professional Quality Vitamins, Nutritional Supplements, OTC Medications, Everyday

Prescriptions, Medical Equipment & Specialty Medications.


PATIENT INFORMATION (Use this area or ĂƩĂĐŚ ƉĂƟĞnt demographiĐs)

Name: ______________________________________ Phone: __________________________ Phone 2: _________________________Home Address: ________________________________________ City: ____________________ State: _______ Zip: _______________ DOB: ______________ SSN: _________________ Sex: Male Female Height: ____________ Weight: _____________Lbs. Allergies: ________________________________________________________________________________________________________

INSURANCE INFORMATION (Use this area or ĂƩĂĐŚ Đopy of insuranĐĞ Đard(s)

Primary Name: _____________________________________ Secondary / RX: _____________________________________________Phone: ___________________________________________ Phone: ____________________________________________________ ID#: _______________________ Group: _______________ ID#: _________________________ Group: ______________________

MEDICAL ASSESSMENT (Use this area or ĂƩĂĐh paƟent labs and other authorizĂƟŽŶ ŝŶĨŽƌŵĂƟŽŶͿ

Primary Diagnosis: ___________________________________ Secondary / Other Diagnosis: ____________________________________ICD9 Code: _________________________________ ICD9 Code: ______________________________________ Previous Treatment(s): _________________________________________ Outcome: __________________________________________ Revlimid® – RevAssist Physican Auth#: ____________ Thalomid® – STEPS Program Physician Auth#: ______________

PRESCRIPTION INFORMATION *(Use this area or ĂƩĂĐŚ Đopy of RX(s)

Prescriber Name: _____________________________________________ NPI#: ____________________________________ Address: _________________________________ City: __________________________ State: _________ Zip: _________ Phone: ______________________________ Fax: ______________________________ Email: _______________________________________ Oĸce Contact: __________________________________________

ONCFRMVS.912

Neupogen Nexavar Perjeta Procrit Revlimid

,ĞƌĐĞƉƟŶ HycamƟn Inlyta :ĂŬĂĮ Neulasta

dĂƌŐƌĞƟŶ Tasigna Temodar Thalomid Tykerb

Votrient Xalkori Xeloda Zelboraf Zolinza

ǇƟŐĂ Other: _____________ Other: _____________

CANCER / ONCOLOGYWƌĞƐĐƌŝƉƟŽŶ Form

Dose / Strength: Sig / ŝƌĞĐƟŽŶƐ ReĮůl(s): ____________ YƵĂŶƟƚǇ ____________ Date: _______________ Prescriber Signature: ___________________________________________________

^ĞůĞĐƚ MediĐĂƟŽŶ / Write in other(s)

This is a list of the most common Specialty Cancer / Oncology medicaƟŽŶƐ American Specialty Pharmacy is available to Įůů all of your ƉĂƟĞŶƚƐ ƉƌĞƐĐƌŝƉƟŽŶ needs. Please include any other medicaƟŽŶƐ your ƉĂƟĞŶƚ needs including IV DĞĚŝĐĂƟŽŶƐ

PRESCRIBER INFORMATION

ĮŶŝƚŽƌ Aranesp AvĂƐƟŶ Erivedge Gleevec

Rituxan Sprycel Sutent Sylatron Tarceva

Treating Patients Special CALL:(877)753-6877 FAX:(888)294-9434 EMAIL: [email protected]

Ship to: PaƟent Home MD KĸĐe

/ŶũĞĐƟŽŶdƌĂŝŶŝŶŐ DKĸĐĞAmerican Specialty to Arrange

FAX TO: (888) 294-9434

Today’s Date

PLEASE ATTACH COPIES OF PATIENT’S INSURANCE CARDS

LOW MOLECULAR WEIGHT REFERRAL FORM

PRESCRIPTION

ǇƐŝŐŶŝŶŐƚŚŝƐĨŽƌŵĂŶĚƵƟůŝǌŝŶŐŽƵƌƐĞƌǀŝĐĞƐǇŽƵĂƌĞĂƵƚŚŽƌŝǌŝŶŐŵĞƌŝĐĂŶĂŶĚŝƚ ƐĞŵƉůŽǇĞĞƐƚŽƐĞƌǀĞĂƐǇŽƵƌƉƌŝŽƌĂƵƚŚŽƌŝǌĂƟŽŶĚĞƐŝŐŶĂƚĞĚĂŐĞŶƚŝŶĚĞĂůŝŶŐǁŝƚŚŵĞĚŝĐĂůĂŶĚƉƌĞƐĐƌŝƉƟŽŶŝŶƐƵƌĂŶĐĞĐŽŵƉĂŶŝĞƐ

Prescriber’s Signature;ƐŝŐŶĂƚƵƌĞƌĞƋƵŝƌĞĚEK^dDW^ͿͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺĂƚĞͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺIMPORTANCE NOTICE: dŚŝƐĨĂǆŝƐŝŶƚĞŶĚĞĚƚŽďĞĚĞůŝǀĞƌĞĚŽŶůǇƚŽƚŚĞŶĂŵĞĚĂĚĚƌĞƐƐĞĞ/ƚĐŽŶƚĂŝŶƐŵĂƚĞƌŝĂůƚŚĂƚŝƐĐŽŶĮĚĞŶƟĂůƉƌŝǀŝůĞŐĞĚƉƌŽƉƌŝĞƚĂƌǇŽƌĞǆĞŵƉƚĨƌŽŵĚŝƐĐůŽƐƵƌĞƵŶĚĞƌ

ĂƉƉůŝĐĂďůĞůĂǁ/ĨǇŽƵĂƌĞŶŽƚƚŚĞŶĂŵĞĚĂĚĚƌĞƐƐĞĞǇŽƵƐŚŽƵůĚŶŽƚĚŝƐƐĞŵŝŶĂƚĞĚŝƐƚƌŝďƵƚĞŽƌĐŽƉǇƚŚŝƐĨĂǆWůĞĂƐĞŶŽƟĨǇƚŚĞƐĞŶĚĞƌŝŵŵĞĚŝĂƚĞůǇŝĨǇŽƵŚĂǀĞƌĞĐĞŝǀĞĚƚŚŝƐĚŽĐƵŵĞŶƚŝŶĞƌƌŽƌĂŶĚƚŚĞŶĚĞƐƚƌŽǇƚŚŝƐĚŽĐƵŵĞŶƚŝŵŵĞĚŝĂƚĞůǇ

&ĂǆĐŽŵƉůĞƚĞĚĨŽƌŵƚŽDZ/E^W/>dzW,ZDzat 888-966-0188

WĂƟĞŶƚEĂŵĞͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺKͺͺͺͺͺͺͺͺͺͺͺͺtĞŝŐŚƚͺͺͺͺͺͺͺDĂůĞ&ĞŵĂůĞ^ƚƌĞĞƚĚĚƌĞƐƐͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺƉƚηͺͺͺͺͺͺͺͺͺŝƚǇͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ^ƚĂƚĞͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺŝƉͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺĂǇƟŵĞWŚͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺǀĞŶŝŶŐWŚͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺĞůůͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺŵĂŝůͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺůůĞƌŐŝĞƐͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ

&ŝƌƐƚ DŝĚĚůĞ >ĂƐƚ

WƌĞƐĐƌŝďĞƌ ƐEĂŵĞͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺKĸĐĞŽŶƚĂĐƚͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ^ƚƌĞĞƚĚĚƌĞƐƐͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ^ƵŝƚĞηͺͺͺͺͺͺͺͺͺŝƚǇͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ^ƚĂƚĞͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺŝƉͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺdĞůͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ&ĂǆͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺŵĂŝůͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ>ŝĐĞŶƐĞηͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺEW/ηͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺhW/Eηͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺηͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ

EtWd/EdhZZEdWd/Ed

FRAGMINϮϱϬϬƵŶŝƚƐϬϮŵů ^ǇƌŝŶŐĞͺͺͺͺͺͺͺYdzͺͺͺͺͺͺͺZĞĮůůͺͺͺͺͺͺͺϱϬϬϬƵŶŝƚƐϬϮŵů ^ǇƌŝŶŐĞͺͺͺͺͺͺͺYdzͺͺͺͺͺͺͺZĞĮůůͺͺͺͺͺͺͺϳϱϬϬƵŶŝƚƐϬϯŵů ^ǇƌŝŶŐĞͺͺͺͺͺͺͺYdzͺͺͺͺͺͺͺZĞĮůůͺͺͺͺͺͺͺϭϬϬϬϬƵŶŝƚƐϭŵů ^ǇƌŝŶŐĞͺͺͺͺͺͺͺYdzͺͺͺͺͺͺͺZĞĮůůͺͺͺͺͺͺͺϭϮϱϬϬƵŶŝƚƐϬϱŵů ^ǇƌŝŶŐĞͺͺͺͺͺͺͺYdzͺͺͺͺͺͺͺZĞĮůůͺͺͺͺͺͺͺϭϱϬϬϬƵŶŝƚƐϬϲŵů ^ǇƌŝŶŐĞͺͺͺͺͺͺͺYdzͺͺͺͺͺͺͺZĞĮůůͺͺͺͺͺͺͺϭϴϬϬϬƵŶŝƚƐϬϳϮŵů ^ǇƌŝŶŐĞͺͺͺͺͺͺͺYdzͺͺͺͺͺͺͺZĞĮůůͺͺͺͺͺͺͺ

LOVENOXϯϬŵŐϬϯŵů ^ǇƌŝŶŐĞͺͺͺͺͺͺͺYdzͺͺͺͺͺͺͺZĞĮůůͺͺͺͺϰϬŵŐϬϰŵů ^ǇƌŝŶŐĞͺͺͺͺͺͺͺYdzͺͺͺͺͺͺͺZĞĮůůͺͺͺͺϲϬŵŐϬϲŵů ^ǇƌŝŶŐĞͺͺͺͺͺͺͺYdzͺͺͺͺͺͺͺZĞĮůůͺͺͺͺϴϬŵŐϬϴŵů ^ǇƌŝŶŐĞͺͺͺͺͺͺͺYdzͺͺͺͺͺͺͺZĞĮůůͺͺͺͺϭϬϬŵŐϭŵů ^ǇƌŝŶŐĞͺͺͺͺͺͺͺYdzͺͺͺͺͺͺͺZĞĮůůͺͺͺͺϭϮϬŵŐϬϴŵů ^ǇƌŝŶŐĞͺͺͺͺͺͺͺYdzͺͺͺͺͺͺͺZĞĮůůͺͺͺͺϭϱϬŵŐϭŵů ^ǇƌŝŶŐĞͺͺͺͺͺͺͺYdzͺͺͺͺͺͺͺZĞĮůůͺͺͺͺ

ARIXTRAϮϱŵŐϬϱŵů sŝĂůͺͺͺͺͺͺͺYdzͺͺͺͺͺͺͺZĞĮůůͺͺͺͺͺͺͺϳϱŵŐϬϲŵů sŝĂůͺͺͺͺͺͺͺYdzͺͺͺͺͺͺͺZĞĮůůͺͺͺͺͺͺͺϭϬŵŐϬϴŵů sŝĂůͺͺͺͺͺͺͺYdzͺͺͺͺͺͺͺZĞĮůůͺͺͺͺͺͺͺ

HEPARIN SODIUMϱϬϬϬƵŶŝƚƐϬϮŵů sŝĂůͺͺͺͺͺͺͺYdzͺͺͺͺͺͺͺZĞĮůůͺͺͺͺͺͺͺϭϬϬϬϬƵŶŝƚƐϬϮŵů sŝĂůͺͺͺͺͺͺͺYdzͺͺͺͺͺͺͺZĞĮůůͺͺͺͺͺͺͺ

OTHERͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺYdzͺͺͺͺͺͺͺͺͺͺZĞĮůůͺͺͺͺͺͺͺͺͺͺ

ADDITIONAL NOTES:

ϮϳϰϯtĞƐƚϭϱƚŚ^ƚƌĞĞƚWůĂŶŽdyϳϱϬϳϱWϴϳϳͲϳϱϯͲϲϴϳϳ&ĂǆϴϴϴͲϵϲϲͲϬϭϴϴ

Today’s Date


PAIN AND EMETIC REFERRAL FORM

PRESCRIPTION








EtWd/EdhZZEdWd/Ed

SIG: ___________________________________________________________________________________________ QTY: _____ Re!ll: _____

Ͳ,ǇĚƌŽĐŽĚŽŶĞŝƚĂƌƚƌĂƚĞϭϬŵŐϮϬŵŐ^ZĂƉƐƵůĞƐ ^ŝŐͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺZĞĮůůͺͺͺͺͺͺͺͲ,ǇĚƌŽĐŽĚŽŶĞŝƚĂƌƚƌĂƚĞϱŵŐϭϬŵŐĂƉƐƵůĞƐ ^ŝŐͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺZĞĮůůͺͺͺͺͺͺͺEŽƌĐŽϭϬϯϮϱŵŐ ^ŝŐͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺZĞĮůůͺͺͺͺͺͺͺ>ŽƌƚĂďϭϬϱϬϬŵŐ ^ŝŐͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺZĞĮůůͺͺͺͺͺͺͺsŝĐŽĚŝŶϱϱϬϬŵŐ ^ŝŐͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺZĞĮůůͺͺͺͺͺͺͺ

Hydrocodone:

ͲKŶĚĂŶƐĞƚƌŽŶϴŵŐ^ZĂƉƐƵůĞƐ ^ŝŐͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺZĞĮůůͺͺͺͺͺͺͺͲKŶĚĂŶƐĞƚƌŽŶϰŵŐϬϭŵ>dŽƉŝĐĂů'Ğů ^ŝŐͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺZĞĮůůͺͺͺͺͺͺͺ

Zofran:

Hydromorphone: ͲͲ,ǇĚƌŽŵŽƌƉŚŽŶĞ,ůϴŵŐϭϬŵŐ^ZĂƉƐƵůĞƐ;DƵƐƚƌĞƋƵŝƌĞŽŶKƌŝŐŝŶĂůͲ//WƌĞƐĐƌŝƉƟŽŶͿ Ͳ,ǇĚƌŽŵŽƌƉŚŽŶĞ,ůϰŵŐĂƐĞdƌŽĐŚĞ;DƵƐƚƌĞƋƵŝƌĞŽŶKƌŝŐŝŶĂůͲ//WƌĞƐĐƌŝƉƟŽŶͿ Ͳ,ǇĚƌŽŵŽƌƉŚŽŶĞ,ůϬϮŵŐ'ƵĂŝĨĞŶĞƐŝŶϮϬŵŐKƌĂů^ǇƌƵƉ;DƵƐƚƌĞƋƵŝƌĞŽŶKƌŝŐŝŶĂůͲ//WƌĞƐĐƌŝƉƟŽŶͿ ,ǇĚƌŽŵŽƌƉŚŽŶĞϮŵŐϰŵŐϴŵŐ;DƵƐƚƌĞƋƵŝƌĞŽŶKƌŝŐŝŶĂůͲ//WƌĞƐĐƌŝƉƟŽŶͿ

Oxycodone: ͲKǆǇĐŽĚŽŶĞ,>ϱŵŐϭϬŵŐϮϬŵŐϯϬŵŐϰϬŵŐ^ZĂƉƐƵůĞƐ;DƵƐƚƌĞƋƵŝƌĞŽŶKƌŝŐŝŶĂůͲ//WƌĞƐĐƌŝƉƟŽŶͿͲKǆǇĐŽĚŽŶĞ,>ϳϱŵŐϭϬŵ>ŽĨƌĂŶ,>ϴŵŐϭϬŵ>KƌĂů^ǇƌƵƉ;DƵƐƚƌĞƋƵŝƌĞŽŶKƌŝŐŝŶĂůͲ//WƌĞƐĐƌŝƉƟŽŶͿKǆǇĐŽĚŽŶĞϭϱŵŐϯϬŵŐ;DƵƐƚƌĞƋƵŝƌĞŽŶKƌŝŐŝŶĂůͲ//WƌĞƐĐƌŝƉƟŽŶͿWĞƌĐŽĐĞƚϭϬϯϮϱŵŐϭϬϲϱϬŵŐϳϱϯϮϱŵŐϳϱŵŐϱϬϬŵŐϱŵŐϯϮϱŵŐ;DƵƐƚƌĞƋƵŝƌĞŽŶKƌŝŐŝŶĂůͲ//WƌĞƐĐƌŝƉƟŽŶͿ

Morphine:ͲDŽƌƉŚŝŶĞ^ƵůĨĂƚĞϭϱϬŵŐϭϴϬŵŐϮϰϬŵŐϮϳϬŵŐϯϬϬŵŐϯϲϬŵŐϰϬϬŵŐ^ZĂƉƐƵůĞ;DƵƐƚƌĞƋƵŝƌĞŽŶKƌŝŐŝŶĂůͲ//WƌĞƐĐƌŝƉƟŽŶͿͲDŽƌƉŚŝŶĞ^ƵůĨĂƚĞWƌŽĐŚůŽƌƉĞƌĂǌŝŶĞϭϬŵŐϭϬŵŐϮϬŵŐϭϬŵŐdƌŽĐŚĞ;DƵƐƚƌĞƋƵŝƌĞŽŶKƌŝŐŝŶĂůͲ//WƌĞƐĐƌŝƉƟŽŶͿD^ŽŶƟŶϯϬŵŐϲϬŵŐϭϬϬŵŐϮϬϬŵŐ^Z;DƵƐƚƌĞƋƵŝƌĞŽŶKƌŝŐŝŶĂůͲ//WƌĞƐĐƌŝƉƟŽŶͿDŽƌƉŚŝŶĞ^ƵůƉŚĂƚĞ/ZϭϱŵŐϯϬŵŐ;DƵƐƚƌĞƋƵŝƌĞŽŶKƌŝŐŝŶĂůͲ//WƌĞƐĐƌŝƉƟŽŶͿ

Fentanyl:Ͳ&ĞŶƚĂŶǇůdƌŽĐŚĞƐϭϬϬŵĐŐϮϬϬŵĐŐ;DƵƐƚƌĞƋƵŝƌĞŽŶKƌŝŐŝŶĂůͲ//WƌĞƐĐƌŝƉƟŽŶͿͲ&ĞŶƚĂŶǇůϬϭŵŐ^ŽƌďŝƚŽůϭϬŐŵ>ŽůůŝƉŽƉ;DƵƐƚƌĞƋƵŝƌĞŽŶKƌŝŐŝŶĂůͲ//WƌĞƐĐƌŝƉƟŽŶͿ&ĞŶƚŽƌĂϭϬϬŵŐϮϬϬŵŐϰϬϬŵŐ;DƵƐƚƌĞƋƵŝƌĞŽŶKƌŝŐŝŶĂůͲ//WƌĞƐĐƌŝƉƟŽŶͿ&ĞŶƚĂŶǇů>ŽǌĞŶŐĞƐϲϬϬDϭϮϬϬϭϲϬϬD;DƵƐƚƌĞƋƵŝƌĞŽŶKƌŝŐŝŶĂůͲ//WƌĞƐĐƌŝƉƟŽŶͿ&ĞŶƚĂŶǇůWĂƚĐŚĞƐϮϱD'ϱϬD'ϭϬϬD';DƵƐƚƌĞƋƵŝƌĞŽŶKƌŝŐŝŶĂůͲ//WƌĞƐĐƌŝƉƟŽŶͿ


Today’s Date


NEUROLOGY & PAIN REFERRAL FORM

PRESCRIPTION


Prescriber’s Signature;ƐŝŐŶĂƚƵƌĞƌĞƋƵŝƌĞĚEK^dDW^ͿͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺĂƚĞͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ/DWKZdEEKd/dŚŝƐĨĂǆŝƐŝŶƚĞŶĚĞĚƚŽďĞĚĞůŝǀĞƌĞĚŽŶůǇƚŽƚŚĞŶĂŵĞĚĂĚĚƌĞƐƐĞĞ/ƚĐŽŶƚĂŝŶƐŵĂƚĞƌŝĂůƚŚĂƚŝƐĐŽŶĮĚĞŶƟĂůƉƌŝǀŝůĞŐĞĚƉƌŽƉƌŝĞƚĂƌǇŽƌĞǆĞŵƉƚĨƌŽŵĚŝƐĐůŽƐƵƌĞƵŶĚĞƌĂƉƉůŝĐĂďůĞ

ůĂǁ/ĨǇŽƵĂƌĞŶŽƚƚŚĞŶĂŵĞĚĂĚĚƌĞƐƐĞĞǇŽƵƐŚŽƵůĚŶŽƚĚŝƐƐĞŵŝŶĂƚĞĚŝƐƚƌŝďƵƚĞŽƌĐŽƉǇƚŚŝƐĨĂǆWůĞĂƐĞŶŽƟĨǇƚŚĞƐĞŶĚĞƌŝŵŵĞĚŝĂƚĞůǇŝĨǇŽƵŚĂǀĞƌĞĐĞŝǀĞĚƚŚŝƐĚŽĐƵŵĞŶƚŝŶĞƌƌŽƌĂŶĚƚŚĞŶĚĞƐƚƌŽǇƚŚŝƐĚŽĐƵŵĞŶƚŝŵŵĞĚŝĂƚĞůǇ DĞĚŝĐĂƌĞĂŶĚDĞĚŝĐĂŝĚŽƌĂŶŽƚŚĞƌƐƚĂƚĞĨƵŶĚĞĚƉƌŽŐƌĂŵǁŝůůŶŽƚĐŽǀĞƌĂďŽǀĞŵĞŶƟŽŶĞĚĐŽŵƉŽƵŶĚƐŽͲƉĂǇŵĞŶƚƐĚƵĞĂƚĚŝƐƉĞŶƐŝŶŐŽĨƚŚĞŵĞĚŝĐĂƟŽŶ

&ĂǆĐŽŵƉůĞƚĞĚĨŽƌŵƚŽDZ/E^W/>dzW,ZDzĂƚϴϴϴͲϵϲϲͲϬϭϴϴ



WƌĞƐĐƌŝďĞƌ ƐEĂŵĞͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺKĸĐĞŽŶƚĂĐƚͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ^ƚƌĞĞƚĚĚƌĞƐƐͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ^ƵŝƚĞηͺͺͺͺͺͺͺͺͺŝƚǇͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ^ƚĂƚĞͺͺͺͺͺͺͺͺͺͺͺŝƉͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺdĞůͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ>ŝĐĞŶƐĞηͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺEW/ηͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺW^ηͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺηͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ

EtWd/EdhZZEdWd/Ed


FIBROMYALGIA (TOPICAL):*AƉƉůǇϯ;ϰϱŐŵͿƉƵŵƉƐƚŽĂīĞĐƚĞĚĂƌĞĂ;ƐͿϯƟŵĞƐĚĂŝůǇůůŽǁĂƚůĞĂƐƚϮϬŵŝŶƚŽĂďƐŽƌď;ϭƉƵŵƉсϭϱŐŵͿ

Ͳ'ƵĂŝĨĞŶĞƐŝŶϭϬйн&ůƵƌďŝƉƌŽĨĞŶϯϱйн<ĞƚĂŵŝŶĞϯйн>ŝĚŽĐĂŝŶĞϮйнWŝƌŽǆŝĐĂŵϭйнǇĐůŽďĞŶǌĂƉƌŝŶĞϭйнDĂŐŶĞƐŝƵŵŚůŽƌŝĚĞϭϬйнWĞƉƉĞƌŵŝŶƚϬϭйͲ&ůƵƌďŝƉƌŽĨĞŶϱйн'ĂďĂƉĞŶƟŶϭϬйн>ŝĚŽĐĂŝŶĞϭϬйн<ĞƚĂŵŝŶĞϭϬйнEŝĨĞĚŝƉŝŶĞϮйнWĞŶƚŽǆǇĨǇůůŝŶĞϮйнůƉŚĂ>ŝƉŽŝĐĐŝĚϮйFORMULAS FOR TOPICAL PAIN/ARTHRITIS/SPASM/NEUROPATHY:ΎŽƐŝŶŐсƉƉůǇϯ;ϰϱŐŵͿƉƵŵƉƐƚŽĂīĞĐƚĞĚĂƌĞĂ;ƐͿϯƟŵĞƐĚĂŝůǇ;ϭƉƵŵƉсϭϱŐŵͿͲ&ůƵƌďŝƉƌŽĨĞŶϱйн'ĂďĂƉĞŶƟŶϭϬйн>ŝĚŽĐĂŝŶĞϭϬйн<ĞƚĂŵŝŶĞϭϬйͲ&ůƵƌďŝƉƌŽĨĞŶϱйн'ĂďĂƉĞŶƟŶϭϬйн<ĞƚĂŵŝŶĞϭϬйн>ŝĚŽĐĂŝŶĞϱйͲ&ůƵƌďŝƉƌŽĨĞŶϭϬйнĂƌďĂŵĂǌĞƉŝŶĞϱйн>ŝĚŽĐĂŝŶĞϭϬйн<ĞƚĂŵŝŶĞϮйͲ&ůƵƌďŝƉƌŽĨĞŶϱйнǇĐůŽďĞŶǌĂƉƌŝŶĞϭйн>ŝĚŽĐĂŝŶĞϰйн'ĂďĂƉĞŶƟŶϯйнĂĐůŽĨĞŶϭйͲŝĐůŽĨĞŶĂĐϱйнWƌŝůŽĐĂŝŶĞϮйн>ŝĚŽĐĂŝŶĞϰйн'ĂďĂƉĞŶƟŶϯйнĂĐůŽĨĞŶϭйͲ&ůƵƌďŝƉƌŽĨĞŶϳйнǇĐůŽďĞŶǌĂƉƌŝŶĞϮйнKƌƉŚĞŶĂĚƌŝŶĞϱйн'ĂďĂƉĞŶƟŶϱйн<ĞƚĂŵŝŶĞϱйͲdƌĂŵĂĚŽůϭϬйнWƌŝůŽĐĂŝŶĞϮйн>ŝĚŽĐĂŝŶĞϰйн'ĂďĂƉĞŶƟŶϯйнĂĐůŽĨĞŶϭй

SHINGLES & TRIGEMINAL NEURALGIA (TOPICAL):ΎƉƉůǇϯ;ϰϱŐŵͿƉƵŵƉƐƚŽĂīĞĐƚĞĚĂƌĞĂ;ƐͿϯƟŵĞƐĚĂŝůǇ;ϭƉƵŵƉсϭϱŐŵͿͲ&ůƵƌďŝƉƌŽĨĞŶϭϬйнĂƌďĂŵĂǌĞƉŝŶĞϱйн>ŝĚŽĐĂŝŶĞϰйн<ĞƚĂŵŝŶĞϮйнϬϮйϮĞŽǆǇͲͲ'ůƵĐŽƐĞнϯйĐǇĐůŽǀŝƌ

WůĞĂƐĞƐƉĞĐŝĨǇďŽĚǇĂƌĞĂͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ

NEUROPATHIC PAIN & ANTI - INFLAMMATORY SPRAY:ΎƉƉůǇϯ;ϭŵůͿƐƉƌĂǇƐƚŽĂīĞĐƚĞĚĂƌĞĂ;ƐͿϰƟŵĞƐĚĂŝůǇͲ&ůƵƌďŝƉƌŽĨĞŶϳϱйнǇĐůŽďĞŶǌĂƉƌŝŶĞϮйнDĞŶƚŚŽůϯйн>ŝĚŽĐĂŝŶĞϮϬйнD^KͲ<ĞƚĂŵŝŶĞϮϬйнDĞƚŚǇů^ĂůŝĐǇůĂƚĞϯϬйнDĞŶƚŚŽůϯйнD^KͲdƌĂŵĂĚŽůϮϬйнǇĐůŽďĞŶǌĂƉƌŝŶĞϮйнWƌŝŽůŽĐĂŝŶĞϮϱйн>ŝĚŽĐĂŝŶĞϭϮϱйнDĞŶƚŚŽůϯйMIGRAINE HEADACHE:ΎWůĞĂƐĞƐƉĞĐŝĨǇĚŽƐĞĂŶĚĨƌĞƋƵĞŶĐǇͲƌŐŽƚĂŵŝŶĞϭŵŐĂīĞŝŶĞϭϬϬŵŐĞůůĂĚŽŶŶĂϭϬŵŐĂƉƐƵůĞͲƌŐŽƚĂŵŝŶĞdĂƌƚƌĂƚĞϮŵŐ^ƵďůŝŶŐƵĂůdĂďůĞƚƐ^ŝŐͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺZĞĮůůƐͺͺͺͺͺͺϭ;KŶĞͿϮ;dǁŽͿϯ;dŚƌĞĞͿ

Cream Size (Pump): 75gm (Seventy-Five Grams)ϭϬϬŐŵ;KŶĞͲ,ƵŶĚƌĞĚ'ƌĂŵƐͿZĞĮůůƐͺͺͺͺͺͺͺϭ;KŶĞͿϮ;dǁŽͿϯ;dŚƌĞĞͿ^ŵĂůůĞƐƚ^ŝǌĞϱϬŐŵ;&ŝŌǇ'ƌĂŵƐͿ

Spray Size:ϲϬŵů;^ŝǆƚǇŵŝůůŝůŝƚĞƌƐͿϭϮϬŵů;KŶĞŚƵŶĚƌĞĚdǁĞŶƚǇŵŝůůŝůŝƚĞƌƐͿZĞĮůůƐͺͺͺͺͺͺͺϭ;KŶĞͿϮ;dǁŽͿϯ;dŚƌĞĞͿ

Today’s Date


CYTOTOXIC, STEROIDS & DIAGNOSTICS

PRESCRIPTION








EtWd/EdhZZEdWd/Ed

Ͳ&ůƵŽƌŽƵƌĂĐŝůKƉŚƚŚĂůŵŝĐ^ŽůƵƟŽŶϭй ^ŝŐͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺZĞĮůůͺͺͺͺͺͺͺͺͺͲdŚŝŽƚĞƉĂϭϮϬϬϬϭϭϬϬϬKƉŚ^ŽůƵƟŽŶ ^ŝŐͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺZĞĮůůͺͺͺͺͺͺͺͺͺͲDŝƚŽŵǇĐŝŶ/ŶũĞĐƟŽŶŽƌKƉŚ^ŽůƵƟŽŶ;ĂůůƐƚƌĞŶŐƚŚƐͿ ^ŝŐͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺZĞĮůůͺͺͺͺͺͺͺͺͺͲDĞƚŚŽƚƌĞǆĂƚĞϰϬϬͲϱϬϬŵĐŐϬϭŵůWƌĞƐĞƌǀĂƟǀĞ&ƌĞĞ ^ŝŐͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺZĞĮůůͺͺͺͺͺͺͺͺͺͲ,ǇĚƌŽǆǇĂŵƉŚĞƚĂŵŝŶĞϭйWƌĞƐĞƌǀĞĚŽƌW&ϱŵů ^ŝŐͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺZĞĮůůͺͺͺͺͺͺͺͺͺͲZŽƐĞĞŶŐĂů^ŽůƵƟŽŶϭйW&ŽƌWƌĞƐĞƌǀĞĚKƉŚ^ŽůƵƟŽŶ^ŝŐͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺZĞĮůůͺͺͺͺͺͺͺͺͺͲZŽƐĞĞŶŐĂů&ůƵƌŽĞƐĐĞŝŶKƉŚƚŚĂůŵŝĐ^ŽůƵƟŽŶ ^ŝŐͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺZĞĮůůͺͺͺͺͺͺͺͺͺͲ^ĂĐĐŚĂƌŝŶ^ŽĚŝƵŵϭϬŵŐŵů ^ŝŐͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺZĞĮůůͺͺͺͺͺͺͺͺͺͲ^ŽĚŝƵŵ^ĂĐĐŚĂƌŝŶϮйKƉŚƚŚĂůŵŝĐ^ŽůƵƟŽŶ ^ŝŐͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺZĞĮůůͺͺͺͺͺͺͺͺͺͲĞǆĂŵĞƚŚĂƐŽŶĞEĂWŚŽƐ/ŶũĞĐƟŽŶϰͲϮϰŵŐŵůW& ^ŝŐͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺZĞĮůůͺͺͺͺͺͺͺͺͺͲĞǆĂŵĞƚŚĂƐŽŶĞ^ŽĚŝƵŵWŚŽƐƉŚĂƚĞW&^ŽůƵƟŽŶƐ ^ŝŐͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺZĞĮůůͺͺͺͺͺͺͺͺͺͲ>ŽƚĞƉƌĞĚŶŽůϬϮϱйW&ΎΎKƉƚŚĂůŵŝĐ^ŽůƵƟŽŶ ^ŝŐͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺZĞĮůůͺͺͺͺͺͺͺͺͺͲDĞƚŚǇůƉƌĞĚŶŝƐŽůŽŶĞEĂ^ƵĐĐŝŶĂƚĞW&KƉŚ^ŽůƵƟŽŶ ^ŝŐͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺZĞĮůůͺͺͺͺͺͺͺͺͺͲZŝŵĞǆŽůŽŶĞϬϱйŽŵƉŽƵŶĚW&ΎΎKƉŚ^ŽůƵƟŽŶ ^ŝŐͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺZĞĮůůͺͺͺͺͺͺͺͺͺ

ĚĚŝƟŽŶĂůEŽƚĞƐ


Today’s Date


COMPOUNDED NON-STERILE REFERRAL FORM

PRESCRIPTION


Prescriber’s Signature;ƐŝŐŶĂƚƵƌĞƌĞƋƵŝƌĞĚEK^dDW^ͿͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺĂƚĞͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ





EtWd/EdhZZEdWd/Ed


/DWKZdEEKd/dŚŝƐĨĂǆŝƐŝŶƚĞŶĚĞĚƚŽďĞĚĞůŝǀĞƌĞĚŽŶůǇƚŽƚŚĞŶĂŵĞĚĂĚĚƌĞƐƐĞĞ/ƚĐŽŶƚĂŝŶƐŵĂƚĞƌŝĂůƚŚĂƚŝƐĐŽŶĮĚĞŶƟĂůƉƌŝǀŝůĞŐĞĚƉƌŽƉƌŝĞƚĂƌǇŽƌĞǆĞŵƉƚĨƌŽŵĚŝƐĐůŽƐƵƌĞƵŶĚĞƌĂƉƉůŝĐĂďůĞůĂǁ/ĨǇŽƵĂƌĞŶŽƚƚŚĞŶĂŵĞĚĂĚĚƌĞƐƐĞĞǇŽƵƐŚŽƵůĚŶŽƚĚŝƐƐĞŵŝŶĂƚĞĚŝƐƚƌŝďƵƚĞŽƌĐŽƉǇƚŚŝƐĨĂǆWůĞĂƐĞŶŽƟĨǇƚŚĞƐĞŶĚĞƌŝŵŵĞĚŝĂƚĞůǇŝĨǇŽƵŚĂǀĞƌĞĐĞŝǀĞĚƚŚŝƐĚŽĐƵŵĞŶƚŝŶĞƌƌŽƌĂŶĚƚŚĞŶĚĞƐƚƌŽǇƚŚŝƐĚŽĐƵŵĞŶƚŝŵŵĞĚŝĂƚĞůǇ DĞĚŝĐĂƌĞĂŶĚDĞĚŝĐĂŝĚŽƌĂŶŽƚŚĞƌƐƚĂƚĞĨƵŶĚĞĚƉƌŽŐƌĂŵǁŝůůŶŽƚĐŽǀĞƌĂďŽǀĞŵĞŶƟŽŶĞĚĐŽŵƉŽƵŶĚƐŽͲƉĂǇŵĞŶƚƐĚƵĞĂƚĚŝƐƉĞŶƐŝŶŐŽĨƚŚĞŵĞĚŝĐĂƟŽŶ

EĂƵƐĞĂΘsŽŵŝƟŶŐͲ>ŽƌĂǌĞƉĂŵϭŵŐŵ>ŝƉŚĞŶŚǇĚƌĂŵŝŶĞ,/ϭϮϱŵŐŵ>,ĂůŽƉĞƌŝĚŽůϮŵŐŵ>DĞƚŽĐůŽƉƌĂŵŝĚĞ,/ϮϬŵŐŵ>dŽƉŝĐĂů>ŝƉŽĚĞƌŵΠ ƉƉůǇϱŐŵŽŶǁƌŝƐƚϯƟŵĞƐĚĂŝůǇĂƐŶĞĞĚĞĚ ͲWƌŽŵĞƚŚĂǌŝŶĞ,/ϮϱŵŐŵ>dŽƉŝĐĂů>ŝƉŽĚĞƌŵΠ ƉƉůǇϱŐŵŽŶǁƌŝƐƚϯƟŵĞƐĚĂŝůǇĂƐŶĞĞĚĞĚ YƵĂŶƟƚǇϯϬŐŵ;dŚŝƌƚǇ'ƌĂŵƐͿ ZĞĮůůƐ ϭ;KŶĞͿϮ;dǁŽͿϯ;dŚƌĞĞͿͲ>ŽƌĂǌĞƉĂŵϭŵŐŝƉŚĞŶŚǇĚƌĂŵŝŶĞ,/ϭϮϱŵŐ,ĂůŽƉĞƌŝĚŽůϮŵŐĂƐĞD<;ůƵĞDŽůĚͿ^ƵƉƉŽƐŝƚŽƌǇ /ŶƐĞƌƚƐƵƉƉŽƐŝƚŽƌǇŝŶƌĞĐƚƵŵƚǁŝĐĞĚĂŝůǇĂƐŶĞĞĚĞĚ YƵĂŶƟƚǇϲϬŐŵ;^ŝǆƚǇ'ƌĂŵƐͿ ZĞĮůůƐ ϭ;KŶĞͿϮ;dǁŽͿϯ;dŚƌĞĞͿƌǇDŽƵƚŚͲ^ŽĚŝƵŵ/ϴϴŵŐWŽƚĂƐƐŝƵŵ/ϯϭŵŐĂůĐŝƵŵ/ϯϰŵŐĂƐĞdƌŽĐŚĞ;ůƐŽƌĞĨĞƌƌĞĚƚŽĂƐĂƐĂůŝǀĂƐƟŵƵůĂŶƚƚƌŽĐŚĞŽƌĞůĞĐƚƌŽůǇƚĞƚƌŽĐŚĞͿ ƉƉůǇϭƚƌŽĐŚĞƵŶĚĞƌƚŽŶŐƵĞƚǁŝĐĞĚĂŝůǇƵŶƟůĚŝƐƐŽůǀĞĚ;ĚŽŶŽƚĐŚĞǁŽƌĐƌƵƐŚͿ YƵĂŶƟƚǇϲϬ;^ŝǆƚǇͿ ZĞĮůůƐ ϭ;KŶĞͿϮ;dǁŽͿϯ;dŚƌĞĞͿͲůĞĐƚƌŽůǇƚĞWŽůǇŐůǇĐŽůdƌŽĐŚĞdDĂƐĞ>ŽůůŝƉŽƉ hƐĞĂƐĚŝƌĞĐƚĞĚKŶĐĞĂŝůǇ;ĚŽŶŽƚĐŚĞǁŽƌĐƌƵƐŚͿ YƵĂŶƟƚǇϯϬ;dŚŝƌƚǇͿZĞĮůůƐ ϭ;KŶĞͿϮ;dǁŽͿϯ;dŚƌĞĞͿ Ͳ^ĂůŝŶĞ'ůǇĐĞƌŝŶKƌĂů^ƵƐƉĞŶƐŝŽŶ;^ĂůŝǀĂƐƵďƐƟƚƵƚĞͿZŝŶƐĞŵŽƵƚŚϯͲϰƟŵĞƐĂƐŶĞĞĚĞĚ;ŽŶŽƚƐǁĂůůŽǁͿ YƵĂŶƟƚǇϮϰϬŵů;dǁŽͲ,ƵŶĚƌĞĚ&ŽƌƚǇDŝůůŝůŝƚĞƌƐͿ ZĞĮůůƐϭ;KŶĞͿϮ;dǁŽͿϯ;dŚƌĞĞͿWĂŝŶͲ<ĞƚĂŵŝŶĞϭϬй'ĂďĂƉĞŶƟŶϲйůŽŶŝĚŝŶĞϬϮйEŝĨĞĚŝƉŝŶĞϮйdŽƉŝĐĂů>ŝƉŽĚĞƌŵΠ Cream Size (Pump)ϲϬŐŵ;^ŝǆƚǇŐƌĂŵƐͿϭϮϬŐŵ;KŶĞŚƵŶĚƌĞĚdǁĞŶƚǇŐƌĂŵƐͿϭϱϬŐŵ;KŶĞŚƵŶĚƌĞĚ&ŝŌǇŐƌĂŵƐͿZĞĮůůƐϭ;KŶĞͿϮ;dǁŽͿϯ;dŚƌĞĞͿͲdĞƚƌĂĐĂŝŶĞ,/Ϭϱй^ŽƌďŝƚŽů>ŽůůŝƉŽƉdDĂƐĞhƐĞĂƐĚŝƌĞĐƚĞĚKŶĐĞĂŝůǇ;ĚŽŶŽƚĐŚĞǁŽƌĐƌƵƐŚͿ YƵĂŶƟƚǇϯϬ;dŚŝƌƚǇͿZĞĮůůƐϭ;KŶĞͿϮ;dǁŽͿϯ;dŚƌĞĞͿƵƌŶŝŶŐDŽƵƚŚ^ǇŶĚƌŽŵĞͲ^ĂůŝĐǇůŝĐĐŝĚϬϯйDŽƵƚŚǁĂƐŚ;ůƐŽƌĞĨĞƌƌĞĚƚŽĂƐD^ŵŽƵƚŚǁĂƐŚͿ ZŝŶƐĞŵŽƵƚŚϯͲϰƟŵĞƐĂƐŶĞĞĚĞĚ;ŽŶŽƚƐǁĂůůŽǁͿ YƵĂŶƟƚǇϮϰϬŵů;dǁŽͲ,ƵŶĚƌĞĚ&ŽƌƚǇDŝůůŝůŝƚĞƌƐͿ ZĞĮůůƐϭ;KŶĞͿϮ;dǁŽͿϯ;dŚƌĞĞͿ

DŽƵƚŚWĂŝŶͲDŝƐŽƉƌŽƐƚŽůϬϬϬϮϰйŝƉŚĞŶŚǇĚƌĂŵŝŶĞ,ůϬϭйŽŵƉŽƵŶĚKƌĂůZŝŶƐĞ;KŌĞŶƌĞĨĞƌƌĞĚƚŽĂƐƌĂĚŝĂƟŽŶďƵƌŶŵŽƵƚŚƌŝŶƐĞͿZŝŶƐĞŵŽƵƚŚϯͲϰƟŵĞƐĂƐŶĞĞĚĞĚ;ŽŶŽƚƐǁĂůůŽǁͿͲ'ůƵƚĂŵŝŶĞDŽƵƚŚǁĂƐŚϮ'ŵϱŵ> ZŝŶƐĞŵŽƵƚŚϯͲϰƟŵĞƐĂƐŶĞĞĚĞĚ;ŽŶŽƚƐǁĂůůŽǁͿ YƵĂŶƟƚǇϮϰϬŵů;dǁŽͲ,ƵŶĚƌĞĚ&ŽƌƚǇDŝůůŝůŝƚĞƌƐͿ ZĞĮůůƐϭ;KŶĞͿϮ;dǁŽͿϯ;dŚƌĞĞͿZĂĚŝĂƟŽŶƵƌŶƐͲůŽĞsĞƌĂsŝƚĂŵŝŶŽůůĂŐĞŶůůĂŶƚŽŝŶ>ĂŶŽůŝŶdŽƉŝĐĂů>ŽƟŽŶͲ<ĞƚŽƉƌŽĨĞŶϮй>ŝĚŽĐĂŝŶĞϮйDŝƐŽƉƌŽƐƚŽůϬϬϬϮϰйWŚĞŶǇƚŽŝŶϮйůŽĞsĞƌĂϬϮйdŽƉŝĐĂůƌĞĂŵͲZĂĚŝĂƟŽŶdŚĞƌĂƉǇ>ŽƟŽŶ YƵĂŶƟƚǇϭϮϬŐŵ;KŶĞͲ,ƵŶĚƌĞĚdǁĞŶƚǇ'ƌĂŵƐͿϭϱϬŐŵ;KŶĞͲ,ƵŶĚƌĞĚ&ŝŌǇ'ƌĂŵƐͿ ZĞĮůůƐϭ;KŶĞͿϮ;dǁŽͿϯ;dŚƌĞĞͿtŽƵŶĚĂƌĞͲWŚĞŶǇƚŽŝŶϮйDŝƐŽƉƌŽƐƚŽůϬϬϬϮϰй>ŝĚŽĐĂŝŶĞϮйƵƉŝǀĂĐĂŝŶĞ,/ϬϮйŝƉŚĞŶŚǇĚƌĂŵŝŶĞ,/ϭйůŽĞsĞƌĂϬϮйͲ<ĞƚŽƉƌŽĨĞŶϮй>ŝĚŽĐĂŝŶĞϮйDŝƐŽƉƌŽƐƚŽůϬϬϬϮϰйWŚĞŶǇƚŽŝŶϮйůŽĞsĞƌĂϬϮйdŽƉŝĐĂůƌĞĂŵ YƵĂŶƟƚǇϭϮϬŐŵ;KŶĞͲ,ƵŶĚƌĞĚdǁĞŶƚǇ'ƌĂŵƐͿϭϱϬŐŵ;KŶĞͲ,ƵŶĚƌĞĚ&ŝŌǇ'ƌĂŵƐͿ ZĞĮůůƐϭ;KŶĞͿϮ;dǁŽͿϯ;dŚƌĞĞͿKƌĂůdŚƌƵƐŚͲůŽƚƌŝŵĂǌŽůĞϴϬŵŐ>ŝĚŽĐĂŝŶĞ,/Ϭϱй^ŽƌďŝƚŽů>ŽůůŝƉŽƉdDĂƐĞhƐĞĂƐĚŝƌĞĐƚĞĚdǁŝĐĞĂŝůǇ;ĚŽŶŽƚĐŚĞǁŽƌĐƌƵƐŚͿͲŵƉŚŽƚĞƌŝĐŝŶϭϬϬŵŐ'ĞůĂƟŶdƌŽĐŚĞƉƉůǇϭƚƌŽĐŚĞƵŶĚĞƌƚŽŶŐƵĞƚǁŝĐĞĚĂŝůǇƵŶƟůĚŝƐƐŽůǀĞĚ;ŽŶŽƚĐŚĞǁŽƌĐƌƵƐŚͿͲŵƉŚŽƚĞƌŝĐŝŶϱϬϬŵŐ^ŽƌďŝƚŽů>ŽůůŝƉŽƉdDĂƐĞhƐĞĂƐĚŝƌĞĐƚĞĚdǁŝĐĞĂŝůǇ;ĚŽŶŽƚĐŚĞǁŽƌĐƌƵƐŚͿ YƵĂŶƟƚǇϮϴ;dǁĞŶƚǇͲŝŐŚƚͿ ZĞĮůůϭ;KŶĞͿϮ;dǁŽͿϯ;dŚƌĞĞͿ

oncology

Documents

mgml prialt

mgml ketamine strengths

mgml methadone strengths

mgml morphine strengths

mgml ropivacaine strengths

mcgml droperidol strengths

mcgml bupivacaine strengths

mcgml hydromorphone