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    Compound RX Form PDF

    Uploaded by

    Gordon Fagras
    The document appears to be a fax order form from a doctor to a pharmacy requesting various topical analgesic creams for a patient including formulations containing baclofen, cyclobenzaprine, ketoprofen, lidocaine and other ingredients for pain relief. It lists the patient and doctor information, diagnoses, insurance details, and signatures for a number of compound cream prescriptions and provides instructions for application and refills.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd

    Compound RX Form PDF

    Uploaded by

    Gordon Fagras
    173 views1 page
    The document appears to be a fax order form from a doctor to a pharmacy requesting various topical analgesic creams for a patient including formulations containing baclofen, cyclobenzaprine, ketoprofen, lidocaine and other ingredients for pain relief. It lists the patient and doctor information, diagnoses, insurance details, and signatures for a number of compound cream prescriptions and provides instructions for application and refills.

    Original Description:

    RX sample form for compounding

    Original Title

    Compound Rx Form (1).pdf

    Copyright

    © Attribution Non-Commercial (BY-NC)

    Available Formats

    PDF, TXT or read online from Scribd

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    The document appears to be a fax order form from a doctor to a pharmacy requesting various topical analgesic creams for a patient including formulations containing baclofen, cyclobenzaprine, ketoprofen, lidocaine and other ingredients for pain relief. It lists the patient and doctor information, diagnoses, insurance details, and signatures for a number of compound cream prescriptions and provides instructions for application and refills.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    173 views1 page

    Compound RX Form PDF

    Uploaded by

    Gordon Fagras
    The document appears to be a fax order form from a doctor to a pharmacy requesting various topical analgesic creams for a patient including formulations containing baclofen, cyclobenzaprine, ketoprofen, lidocaine and other ingredients for pain relief. It lists the patient and doctor information, diagnoses, insurance details, and signatures for a number of compound cream prescriptions and provides instructions for application and refills.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 1

    FAX: 888-247-6685

    Doctor Name: Address: City: DEA#: Patient Name: Address: City: Person Faxing: Phone#: State: Med Lic#: Date of Birth: Phone#: State:
    front & back):

    -or-Scan: compoundingscripts@gmail.com
    Fax#: Zip: NPI:

    Cell#: Zip:

    PATIENT INSURANCE INFORMATION ( oryou may provide a copy of the patients card Insurance Carrier: Claim #: Group #:

    W/C A djuster: BIN #: Pt ID #:

    Phone: (

    Patient Diagnosis:

    LABEL RX IN SPANISH

    TOPICAL ANALGESIC THERAPY CREAMS


    1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12.

    BACLOFEN 2% - CYCLOBENZAPRINE 2% - KETOPROFEN 15% - LIDOCAINE 5% (BCKL)


    (INFLAMMATION/SWELLING/PAIN RELIEF OF MUSCLES, TENDONS, LIGAMENTS, JOINTS, BONES MUSCLE SPASMS/STIFFNESS W/ LOCAL ANALGESIA)

    BCKL DC102 DIL GKKL K20 MEDROX TEROCIN KC-5 DKGL 1 DKGL 2 DENDRACIN DMSO

    DICLOFENAC 10% - CYCLOBENZAPRINE 2% (DC102)


    (INFLAMMATION/SWELLING/PAIN/FEVER RELIEF OF MUSCLES, TENDONS, JOINTS RHEUMATISM)

    DICLOFENAC 6% - INDOMETHACIN 6% - LIDOCAINE 5% (DIL)


    (INFLAMMATION/SWELLING/PAIN RELIEF OF JOINTS, BONES, SOFT TISSUE WITH LOCAL ANALGESIA - ARTHRITIS - GOUT)

    GABAPENTIN 10% - KETOPROFEN 10% - KETAMINE 10% - LIDOCAINE 5% (GKKL)


    (INFLAMMATION/SWELLING/PAIN RELIEF OF JOINTS, BONES, SOFT TISSUE WITH LOCAL ANALGESIA NEUROPATHIC PAIN)

    KETOPROFEN 20% - ULTRADERM BASE 120% (K20)


    (INFLAMMATION/SWELLING/PAIN/FEVER RELIEF IN BODY ARTHRITIS RHEUMATISM OSTEOARTHRITIS TENDONITIS BURSITIS)

    METHYL SALICYLATE 20% - MENTHOL 5% - CAPSAICIN 0.0375% (MEDROX OINTMENT)


    (INFLAMMATION/PAIN RELIEF OF MUSCLES, JOINTS, NERVES IMPROVES FUNCTIONALITY & MOBILITY)

    METHYL SALICYLATE 25% - CAPSAICIN 0.025% - MENTHOL 10% - LIDOCAINE 2.50% (TEROCIN LOTION)
    (INFLAM./PAIN RELIEF OF MUSCLES/JOINTS ARTHRITIS/TENDONITIS STRAINS POSTHERPETIC NEURALGIA DIABETIC NEUROPATHY SHINGLES)

    KETOPROFEN 10% - CAPSAICIN 0.05% - MENTHOL 5% - CAMPHOR 5% (KC-5)


    (INFLAM./SWELLING/PAIN/FEVER RELIEF ARTHRITIS/TENDONITIS/OSTEOARTHRITIS RHEUMATISM BURSITIS DIABETIC NEUROPATHY NEURALGIAS)

    DICLOFENAC 10% - KETAMINE 10% - GABAPENTIN 10% - LIDOCAINE 5% (DKGL 1)


    (INFLAMMATION/SWELLING/PAIN RELIEF OF JOINTS, BONES, SOFT TISSUE ACUTE & NEUROPATHIC PAIN SCIATICA WITH LOCAL ANALGESIA)

    DICLOFENAC 10% - KETOPROFEN 10% - GABAPENTIN 10% - LIDOCAINE 5% (DKGL 2)


    (SAME AS DKGL1, BUT SUBSTITUTE KETOPROFEN FOR KETAMINE FOR JOINTS, BONES, SOFT TISSUE)

    METHYL SALICYLATE 30% - MENTHOL 10% - CAPSAICIN 0.0375% (DENDRACIN)


    (OSTEOARTHRITIS POSTHERPETIC NEURALGIA DIABETIC NEUROPATHY POST-MASTECTOMY PAIN)

    KETOPROFEN 20% - DIMETHYL SULFOXIDE 5% (DMSO CREAM)


    (INFLAMMATION/SWELLING/PAIN/FEVER RELIEF IN BODY ARTHRITIS RHEUMATISM OSTEOARTHRITIS TENDONITIS BURSITIS)

    OTHER FORMULATIONS, ADDITIONS OR CHANGES:

    *Please indicate Quantity:

    120 GM

    240 GM

    Alternate Quantity

    SIG: Apply 1-2 GRAMS to affected area 3-4 times daily. ALTERNATE SIG:
    *NOTE: PLEASE CROSS OUT ANY UNWANTED MEDICATION IN ABOVE FORMULATIONS

    PHYSICIAN SIGNATURE:

    DATE:

    # REFILLS:

    AUTO REFILL:

    Legal Note: This fax transmission may contain confidential information belonging to the sender, which is legally privileged. This information is intended only for the use of the recipient named above. If you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution, or taking of any action in reliance on the contents of this faxed information is strictly prohibited. Please notify us by phone to arrange for the return of the original documents.

    Valley View Drugs, Inc.

    Ph: 866-941-1208

    Fax: 8 8 8-247-6685

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