Prescription Order Form
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1
2Prescription Order Form
(316) 721-4823
West location fax:
(316) 636-9591
East location fax:
Name____________________________________________ DOB______/______/____________ Cell Phone ( ______ ) _______ - _____________
Address___________________________________________________ City____________________________ ST_________ Zip_________________
Allergies ____________________________________________ Current Medications______________________________________________________
Diagnosis/ICD-9 Code_______________________________ Insurance Co____________________________ Policy#_________________________
Worker’s Comp:
Yes
No
Case # ___________________________
All items may be modified. Please make additions or modifications as necessary. Blanks provided for controlled substances.
Anti-Inflammatory Creams
1.
Flurbiprofen 10%, Baclofen 2%, Cyclobenzaprine 2%, Lidocaine 5% Cream
(FBCT)
Neuropathic Creams
2.
_______________ ____%, Baclofen 2%, Cyclobenzaprine 2%, Gabapentin 6%, Amitriptyline 2%, Lidocaine 5% Cream
(K10BCGL)
Combination Creams
3.
_______________ ____%, Cyclobenzaprine 2%, Diclofenac 3%, Gabapentin 6%, Orphenadrine 5%, Lidocaine 5% Cream
(K10CDGOT)
Quantity (circle one): 120gm
180gm
240gm
Refills:
PRN
or ________
Sig: Apply 1 to 2 Grams to affected area 3 to 4 times daily. (1 pump = 1 gram)
Shingles Cream
4.
Gabapentin 6%, Amitriptyline 2%, Clonidine 0.2%, Ketoprofen 10%
(GACK)
Acyclovir 2% and Deoxy-D-Glucose 0.1%
Lidocaine 5%
Quantity: 240 gm
Refills: ____
Sig: Apply three times daily until 1 week after symptoms
resolve or signs of infection are no longer present.
Migraine Cream
3
5.
_______________ ____%, Sumatriptan 5%, Gabapentin 3%, Diclofenac 3%, Ondansetron 0.25%, Caffeine 1% Cream
SGDO)
(K
Quantity: 60gm unless otherwise indicated here ___________
Refills:
PRN
or ________
Sig: Apply 0.5 to 1 gram to the base of the skull at onset of headache. May repeat in 2 hours if needed.
Scar Gels
6. (BTLNEWScar) Betamethasone Valerate 0.1%, Tranilast 1%, Levocetirizine 2% Gel
7. (VPOLDScar) Verapamil 5%, Pentoxifylline 0.3% Gel
OPTIONAL:
Gabapentin 15% and Lidocaine 3%
Quantity
: 60gm
120gm
Refills:
PRN
or ________
(circle one)
Sig: Apply 0.25 to 1 gram twice daily to scar tissue.
X__________________________________________
X__________________________________________
Date _____________________
Dispense as Written
Substitution Permitted
Physician____________________________ DEA#_________________ NPI#___________________ Phone ( ______ ) _______ - _____________
Address___________________________________________________ City____________________________ ST_________ Zip_________________
Office Contact___________________________________________________ Fax ( ______ ) _______ - _____________
Form: TPSF EC 101034
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Parent category: Medical