Prescription Order Form (Page 2 of 2) in pdf

Prescription Order Form Page 2

Patient Instructions - Transdermal Cream

A Custom Made Prescription

Your doctor has prescribed a topical cream that should be applied to your skin. This prescription is a

custom compounded medication that is made specifically for you. Because your doctor cares about

the quality of the medication and care you receive, your doctor is sending your prescription to Custom

Rx Pharmacy, a PCAB Accredited

compounding pharmacy.

Expect A Call From Custom Rx

Our patient care team will collect the necessary information to fill your prescription including your

name, address, phone, birthday, allergies and prescription insurance information. The representative

will be happy to answer any questions you may have about your prescription or the process. You are

welcome to speak with a pharmacist at any time - just ask!

Application Is Easy

1. Clean and dry the application area.

2. With clean hands, apply the directed amount, usually 1-2 pumps.

3. Rub in well - one to two minutes depending on the size of the application area. You may add a

couple drops of water during application to reduce tackiness.

4. Wash hands well to remove any remaining medication.

5. Do not wash the area for at least 45 minutes.

Neuropathic Pain Dermatome Chart

Neuropathic Pain

Neuropathic pain is a specific type of pain that sends pain sig-

nals through the nervous system. In order to reduce the effect of

these signals your doctor may ask you to apply your medication

to the site of pain as well as the corresponding nerve receptor

along your spine. The Dermatome Chart at right indicates these

locations and should be marked by your doctor if you have neu-

ropathic related pain.

Questions? Call Us!

1-855-287-6879

Form: TPSF2B

Prescription Order Form Page 2