Im Primis RX Formulation
Im Primis RX Formulation
Im Primis RX Formulation
6979)
I m p r i m i s R x
Formulation Catalog
CURCUMIN (EMULSION)
Unique preparation prepared in a sterile environment
Convenience of proper dosing for single use
Cost effective
ASCORBIC ACID
May be stored at room temperature
Physician preferred non-corn source
WWW.IMPRIMISRX.COM
1
TABLE OF CONTENTS
PAG E
2 | OVERVIEW 13 | SUPPOSITORIES
6 | INSTILLATIONS 15 | QUALITY
Imprimis Pharmaceuticals (Nasdaq: IMMY) is a pharmaceutical company dedicated to delivering high quality and innovative
compounded preparations to physicians and patients at affordable prices. We are pioneering a new commercial pathway in
the pharmaceutical industry, using compounding pharmacies for the formulation and dispensing of high quality, compounded
formulations. We are focused in many therapeutic areas including ophthalmology, urology, sinus and integrative medicines.
ImprimisRx pharmacies are committed to delivering customized
and other compounded formulations to physicians and patients
TODAY at accessible prices.
Ease of dosing
We specialize in a variety of condition areas and focus on developing compounded formulations for individual
patients. A sample of the areas where physicians have requested specific formulations include:
Surfactants Ophthalmology
Myers Cocktail Injectable formulations
Topical formulations
Dermatologic conditions Sublingual formulations
Acne therapies
Wart therapies
Men & womens health
Estrogen/testosterone
Endocrine/metabolic health
Interstitial cystitis intravesical formulations
Vitamins
Interstitial cystitis oral treatments
Botanicals
Intracavernous injections for erectile dysfunction
The formulations contained in the catalog are just a sample of the compounded preparations that may be formulated for
individually identified patients pursuant to a prescription or order from a physician. The physician, patient, and pharmacist
should determine the compound that is most appropriate for the particular patient.
3
COMPOUNDED FORMULATIONS
PF=Preservative Free
**indicates maximum BUD is 45 days frozen
Example compounded formulations and dosage, strength, and forms are examples ONLY. Each formulation is compounded by a
pharmacist pursuant to a prescription to meet the needs of individual patients.
4 Please contact us for alternate formulations at (844) 446-6979.
COMPOUNDED FORMULATIONS
Intraocular Formulations
Dex-Moxi (Dexamethasone/Moxifloxacin) 1mg/5mg/mL 1mL
Epinephrine/Lidocaine in BSS (Shugarcaine) PF 0.025/0.75% 2mL
Epinephrine Lyophilized 1mg/mL 1mL
Moxifloxacin 5mg/mL 1mL
Phenylephrine/Lidocaine PF 1.5/1% 1mL
Tri-Moxi (Triamcinolone/Moxifloxacin) PF 15mg/1mg/mL single-use vial
Tri-Moxi-Vanc (Triamcinolone/Moxifloxacin/Vancomycin) PF 15mg/1mg/10mg/mL single-use vial
Vancomycin PF 10mg/mL 1mL
PF=Preservative Free
**indicates maximum BUD is 45 days frozen
Example compounded formulations and dosage, strength, and forms are examples ONLY. Each formulation is compounded by a
pharmacist pursuant to a prescription to meet the needs of individual patients.
5
Please contact us for alternate formulations at (844) 446-6979.
COMPOUNDED FORMULATIONS
Intracavernous Injections
Bimix Solution (Phentolamine/Prostaglandin) 1mg/20mg/mL 10mL
Pentoxifylline PF 20mg/mL 1mL
Priapism Kit-Phenylephrine 1% 1mL/NaCl 0.9% 10mL 1 dose
Priapism Kit-Phenylephrine 1% 1mL/NaCl 0.9% 10mL 5 doses
Priapism Kit-Phenylephrine 1% 1mL/NaCl 0.9% 10mL 10 doses
Trimix Solution (Phent / Papav / Atropine) 4mg/30mg/0.2mg/mL 5mL
Trimix Solution (Phent / Papav / PGE1) 0.2mg/10mg/10mcg/mL 10mL
Trimix Solution (Phent / Papav / Prostaglandin) 2mg/30mg/20mcg/mL 10mL
Trimix-L I Lyophilized (Phent / Papav / PGE5) 0.5mg/10mg/5mcg/0.5/mL 10 doses
Trimix-L II Lyophilized (Phent / Papav / PGE5) 1mg/15mg/10mcg/0.5/mL 10 doses
Trimix-L III Lyophilized (Phent / Papav / PGE5) 1mg/15mg/20mcg/0.5/mL 10 doses
INSTILLATIONS
Gentamicin Bladder Irrigation 0.048% 900mL
Hep-Lido-A (heparin, alkalinized lidocaine) 3,300u/13.25mg/mL 20mL
Heparin, Lidocaine HCI 2%, Sodium Bicarbonate 10,000u/2%/4% 10 doses/20mL
ORAL MEDICATIONS
Capsules
Amphotericin CF/GF/DF 100mg capsule Qty 60
Amphotericin CF/GF/DF 250mg capsule Qty 90
Anastrozole capsule Qty 30
Biosolve-PA - DMPS/Alpha Lipoic Acid/Bismuth Subnitrate 25mg/100mg/200mg capsule Qty 100
Colchicine/Indomethacin 0.6mg/25mg capsule Qty 30
Colchicine/Indomethacin 0.6mg/50mg capsule Qty 30
DMSA 100mg capsule Qty 15
DMSA 250mg capsule Qty 15
DMSA 500mg capsule Qty 15
DMPS 500mg capsule Qty 1
PF=Preservative Free
**indicates maximum BUD is 45 days frozen
Example compounded formulations and dosage, strength, and forms are examples ONLY. Each formulation is compounded by a
6 pharmacist pursuant to a prescription to meet the needs of individual patients.
Please contact us for alternate formulations at (844) 446-6979.
COMPOUNDED FORMULATIONS
PF=Preservative Free
**indicates maximum BUD is 45 days frozen
Example compounded formulations and dosage, strength, and forms are examples ONLY. Each formulation is compounded by a
pharmacist pursuant to a prescription to meet the needs of individual patients. 7
Please contact us for alternate formulations at (844) 446-6979.
COMPOUNDED FORMULATIONS
Suspension
Amphotericin B, CF/GF 250mg/5mL 450mL
Fluconazole Susp CF/GF/DF/AF/SF 25mg/mL 10mL
Fluconazole Susp CF/GF/DF/AF/SF 100mg/mL 60mL
Ketoconazole, GF/CF 100mg/5mL Qty 150
Metronidazole 250mg/5mL 160mL
Vancomycin 250mg/5mL 60mL
Nystatin CF/GF/DF/AF/SF <1gm powder
Nystatin CF/GF/DF/AF/SF 1-2gm powder
Sublingual Formulations
DHEA Troche 8mg Qty 30
DHEA Troche 25mg Qty 30
HCG Sublingual Oil Drops (Controlled) 500u/0.5mL 15mL
HCG/Methylcobalamin, Sublingual (Controlled) 500u/300mcg each
HCG Lemon Sublingual Troche, (Controlled) 500u each
HCG SL Spray (Controlled) 125 units/spray 5mL
HCG SL Spray (Controlled) 125units/spray 2x5mL
Midazolam/Ketamine HCl/Ondansetron, Sublingual Lemon (Controlled) 3/25/2mg Qty 2
Oxytocin Lemon Sublingual Troche 50u Qty 30
Oxytocin Sublingual Troche 100u each
Oxytocin Sublingual Troche 200u each
Testosterone Sublingual Drops, (Controlled) 0.5/mg 10mL
Testosterone Troche, (Controlled) 50mg Qty 30
Testosterone Troche, (Controlled) 100mg Qty 30
PF=Preservative Free
**indicates maximum BUD is 45 days frozen
Example compounded formulations and dosage, strength, and forms are examples ONLY. Each formulation is compounded by a
8 pharmacist pursuant to a prescription to meet the needs of individual patients.
Please contact us for alternate formulations at (844) 446-6979.
COMPOUNDED FORMULATIONS
Cream/Gels
Alpha-Arbutin/Retinoic Acid/Hydrocortisone 50gm
Azelaic Acid/Permethrin Cream 30gm
BiEstrogen Cream 30gm
BiEstrogen Cream 60gm
BiEstrogen Cream 90gm
BLT (Benzocaine/Lidocaine/Tetracaine/Plasticized Base) 20/8/6% 30gm
BLT (Benzocaine/Lidocaine/Tetracaine/Plasticized Base) 20/8/6% 60gm
BLT (Benzocaine/Lidocaine/Tetracaine/Plasticized Base) 20/8/6% 100gm
CoQ10/Asc Palm/DMAE/Lipoic Acid 30gm
Curcumin Liposomal Vaginal Cream 5% 30gm
Curcumin Silomac Gel 5% 30gm
DMAE/Glycolic Acid/Niacinamide/Estriol/Vit C, Cream 3/5/2/0.3/5% 30gm
DMAE/Niacinamide/Ascorbyl Palmitate/Glycolic Acid/Estriol) 30gm
DMPS Topical Gel 15mL
DMPS Topical Gel 30mL
Estradiol/Estriol Cream 30gm
Estradiol/Estriol Cream 60gm
Estradiol/Estriol Cream 90gm
Glutathione LippoGel 250mg/mL 30mL
Glutathione LippoGel 250mg/mL 60mL
Glutathione LippoGel 500mg/mL 30mL
Glutathione LippoGel 500mg/mL 60mL
Green Tea Extract Liposomal Vaginal Cream 2% 30gm
Green Tea Extract Liposomal Vaginal Cream 15% 30gm
HCG Lipoderm Gel, (Controlled) 250u/mL 30gm
Hydroquinone/Retinoic Acid/Hydrocortisone 6/1/0.1% 30gm
Hydroquinone/Ascorbic Acid Silomac 30gm
Hyaluronic Acid Serum, Serum 0.1% 30gm
Hyaluronic Acid/Aloe Vera 0.2%/0.2% 15mL
Kojic Acid/Arbutin Serum SiloMac 30mL
PF=Preservative Free
**indicates maximum BUD is 45 days frozen
Example compounded formulations and dosage, strength, and forms are examples ONLY. Each formulation is compounded by a
pharmacist pursuant to a prescription to meet the needs of individual patients. 9
Please contact us for alternate formulations at (844) 446-6979.
COMPOUNDED FORMULATIONS
Intranasal
Acetylcysteine 200mg 60u
Amphotericin B 0.5mg 60u
Amikacin 150mg 60u
Azithromycin 70mg 60u
Betamethasone 0.5mg 60u
Budesonide 0.6mg 60u
Cefazolin 200mg 60u
Cefepime 200mg 60u
Ceftazidime 600mg 60u
Ceftriaxone 200mg 60u
Cefuroxime 300mg 60u
PF=Preservative Free
**indicates maximum BUD is 45 days frozen
Example compounded formulations and dosage, strength, and forms are examples ONLY. Each formulation is compounded by a
pharmacist pursuant to a prescription to meet the needs of individual patients.
10 Please contact us for alternate formulations at (844) 446-6979.
COMPOUNDED FORMULATIONS
PF=Preservative Free
**indicates maximum BUD is 45 days frozen
Example compounded formulations and dosage, strength, and forms are examples ONLY. Each formulation is compounded by a
pharmacist pursuant to a prescription to meet the needs of individual patients.
11
Please contact us for alternate formulations at (844) 446-6979.
COMPOUNDED FORMULATIONS
Ocular Solutions
Mydriatic 3 - Tropi-Cyclo-Phenyl (Tropicamide/Cyclopentolate/Phenylephrine) 1/1/2.5% 1mL Dropper
Mydriatic 4 - Tropi-Prop-Phenyl-Ketor
Tropicamide/Proparacaine/Phenylephrine/Ketorolac) 1/0.5/2.5/0.5% 1mL Dropper
Povidone Iodine PF Solution 5% 1mL Dropper
Pred-Ketor (Prednisolone Acetate/Ketorolac Tromethamine) 1/0.4% 3mL Dropper
Pred-Moxi (Prednisolone Acetate/Moxifloxacin Hydrochloride) 1/0.5% 3mL Dropper
Pred-Moxi (Prednisolone Acetate/Moxifloxacin Hydrochloride) 1/0.5% 6mL Dropper
Pred-Moxi-Ketor (Prednisolone Acetate/Moxifloxacin Hydrochloride/Keterolac) 1/0.5/0.4% 3mL Dropper
Pred-Moxi-Ketor (Predinisolone acetate/Moxifloxacin Hydrochloride/Keterolac) 1/0.5/0.4% 6mL Dropper
Pred-Moxi-Nepaf (Prednisolone acetate/Moxifloxacin Hydrochloride/Nepafenac) 1/0.5/0.1% 5mL Dropper
Tri-Moxi (Triamcinolone Acetonide/Moxifloxacin HCI) 1.5/0.5% 3mL Dropper
Solutions
Dutasteride Solution 60mL
Glycolic Acid High Purity 10 - 30% 30mL
Glycolic Acid High Purity 40 - 60% 30mL
Glycolic Acid High Purity 70% 30mL
Jessners (Salicylic Acid/Resorcinol/Lactic Acid) 14/14/14% 30mL
Jessners, Ultra W/HQ 4% 30mL
Minoxidil/Azelaic Acid/Retinoic Acid/Betamethasone 60mL
Minoxidil/Finasteride Solution 60mL
Minoxidil/Dutasteride Solution 60mL
Phenol USP Soln 30mL
Pilocarpine PF Solution 2% 1mL Dropper
Retinoic Acid/Niacinamide/Ascorbic Acid 30gm
Salicylic Acid Cleanser 2% 60mL
Salicylic Acid/Glycolic Acid Solution 60mL
Spironolactone Cream/Solution 30ml
Spironolactone/Minoxidil Solution 60mL
Spironolactone/Retinoic Acid Solution 60mL
PF=Preservative Free
**indicates maximum BUD is 45 days frozen
Example compounded formulations and dosage, strength, and forms are examples ONLY. Each formulation is compounded by a
pharmacist pursuant to a prescription to meet the needs of individual patients.
12 Please contact us for alternate formulations at (844) 446-6979.
COMPOUNDED FORMULATIONS
SUPPOSITORIES
Curcumin Liposomal Vaginal Suppository 250mg each
Curcumin Liposomal Vaginal Rectal Suppository 250mg each
DMSA/Glutathione Suppository 300mg/300mg Qty 10
DMSA/Glutathione Suppository 300mg/300mg Qty 30
Green Tea Extract Vaginal Suppository 150mg Qty 30
Green Tea Extract Rectal Suppository 150mg Qty 30
OTHER
Active Sinus Saline Rinse
NasaTouch Atomizer
NasoNeb Atomizer
Neilmed Saline Rinse
PF=Preservative Free
**indicates maximum BUD is 45 days frozen
Example compounded formulations and dosage, strength, and forms are examples ONLY. Each formulation is compounded by a
pharmacist pursuant to a prescription to meet the needs of individual patients.
Please contact us for alternate formulations at (844) 446-6979. 13
COMMERCIAL FORMULATIONS
INJECTABLES
Amino Acids Infusion Bag 8.5% 500mL
Arginine HCL 100mg/mL 300mL
Bacteriostatic Water for Injection 30mL
Calcium Gluconate PF 10% 10mL
Carnitor (levocarnitine) 200mg/mL 5mL
Cyanocobalamin (B12) MDV 1mg/mL 30mL
Dexamethasone MDV 4mg/mL 30mL
Dextrose PF 50% 50mL
Folic Acid MDV 5mg/mL 10mL
Freamine 10% 1000mL
Heparin Sodium 10,000u/mL 2mL
Hyaluronidase PF 150u/mL 2mL
Hydroxocobalamin MDV 1mg/mL 30mL
Leucovorin Calcium 50mg 1 vial
Leucovorin Lyophilized 100mg 1 vial
Lidocaine HCL 1% 50mL
Lidocaine HCL 2% 50mL
Magnesium Chloride MDV 200mg/mL 50mL
Magnesium Sulfate PF 50% 10mL
Mannitol PF 25% 50mL
Selenium PF 40mcg/mL 50mL
Sodium Bicarbonate 8.4% 50mL
Sterile Water for Injection 50mL
Testosterone Cypionate
Thiamine HCL (B1) MDV 100mg/mL 2mL
Vitamin B-Complex-100 MDV 30mL
Zinc Sulfate 5mg/mL 5mL
ORAL TREATMENTS
Alpha Lipoic Acid 300mg 60 capsules
Armour Thyroid 60mg 30 capsules
Elmiron 100mg 90 capsules
Nature Thyroid 65mg 30 capsules
WP Thyroid 65mg 30 capsules
Example compounded formulations and dosage, strength, and forms are examples ONLY. Each formulation is compounded by a
pharmacist pursuant to a prescription to meet the needs of individual patients.
14 Please contact us for alternate formulations at (844) 446-6979.
COMPOUNDING WITH AN
IMPRIMISRX PHARMACY
All prescriptions at an ImprimisRx pharmacy are prepared by highly specialized pharmacists. They
work closely with practitioners and patients to maximize potential therapeutic outcomes using the latest
technology, peer-reviewed literature and high quality of active pharmaceutical ingredients (APIs) from
FDA-registered facilities.
Our compounding pharmacies operate under the regulatory framework of the Drug Quality &
Security Act (2013), Section 503A of the Federal Food, Drug, and Cosmetic Act (FFDCA) and applicable state
pharmacy laws.
We believe our internal quality assurance standards and best practice policies meet or exceed those required
under the U.S. Pharmacopeia (USP) and state pharmacy laws in certain important respects. This includes
regular quarterly external quality assurance and quality control inspections of our pharmacy operations, in
addition to our own policy to send all sterile batches of our formulations to an FDA-registered laboratory for
third-party testing, prior to shipment.
15
ImprimisRx is commited to delivering high-quality
formulations that meet all
U.S. PHARMACOPEIA <797> & <795> & PCAB REQUIREMENTS
All Sterile Lots All Sterile Injectable Lots -14 Days for Sterility
Result
Daily Monitoring Sterility & Endotoxin Stability Study Data
Reports
COMPOUNDING QA PROGRAM
PERSONNEL
ENVIRONMENT DOCUMENTATION &
POLICIES
Initial Aseptic Training Semi-
All Aseptic in ISO5
Written SOPs
Annual Evaluations Disinfectant
How to Order
To begin prescribing our compounded formulations, please visit imprimisrx.com or call us today
at 844.4.IMMYRX (844.446.6979)
WWW.IMPRIMISRX.COM
CALL 844.446.6979
16 FAX YOUR ORDERS TO 949.551.1950
HOW TO ORDER
Billed to healthcare provider.
SET UP AN ACCOUNT
1 Fill out the Account Setup forms along with the credit application and email
them to clientservices@imprimispharma.com. Once your completed forms are
received, your account will be set up within 48 hours.
2 PLACING AN ORDER
There are 4 easy ways to place an order with an ImprimisRx pharmacy:
Fax your completed prescription order form to 949.551.1950
Call toll-free at 844.4.IMMYRX (844.446.6979)
SureScripts
E-scribe through our online Doctor Portal at http://doctors.imprimisrx.com
RELAX
4
Once your order is received, it will be processed and shipped within 72 hours.
For your convenience, we can confirm your order once received if requested.
17
HOW TO ORDER
Billed to patient.
1 PLACING AN ORDER
There are 4 easy ways to place an order with an ImprimisRx pharmacy:
Fax your completed prescription order form to 949.551.1950
Call toll-free at 844.4.IMMYRX (844.446.6979)
SureScripts
E-scribe through our online Doctor Portal at http://doctors.imprimisrx.com
3 RELAX
Our customer service team will take care of the prescription from this point on. We will
contact your patient directly to verify prescription and insurance information and any
co-payments. Orders will be processed and shipped within 72 hours.
18
Imprimis Cares Order Form
Patient: DOB:
Age: M F Tel: Home
Work: Cell:
Address:
Shipping (check one)
City: ST: Zip:
FedEx Overnight FedEx 2 Day FedEx Ground
Please allow for 72 hours turnaround time (3 business days) before order will ship.
Incomplete orders may delay processing. Bill to Office Ship to Office Ship to Patient
If you need a medication not listed, please contact us at 844-446-6979 (toll-free)
Dermatology
Other: ________________
*Prescribers are reminded that state law allows patients to receive medications from a pharmacy of their choice
**Representative formulation. Please contact us for an alternate formulation. Customizable within certain ranges.
Payment Information
Credit Card Number: Expiration: CVC/Code: Billing Zip:
Patient: DOB:
Medication Allergies
Age: M F Tel: Home
Work: Cell:
Address:
City: ST: Zip:
Pred-Moxi (Prednisolone Acetate/Moxifloxacin 3mL Instill into the affected eye(s) following the
Hydrochloride) 1/0.5%** instructions provided by your prescriber
Pred-Moxi (Prednisolone Acetate/Moxifloxacin Instill into the affected eye(s) following the
6mL instructions provided by your prescriber
Hydrochloride) 1/0.5%**
Pred-Ketor (Prednisolone Acetate/Keterolac Instill into the affected eye(s) following the
Tromethamine) 1/0.4%** 3mL instructions provided by your prescriber
Pred-Moxi-Ketor (Prednisolone Acetate/Moxifloxacin 3mL Instill into the affected eye(s) following the
Hydrochloride/Keterolac Tromethamine) 1/0.5/0.4%** instructions provided by your prescriber
Pred-Moxi-Nepaf (Prednisolone Acetate/Moxifloxacin Instill into the affected eye(s) following the
5mL instructions provided by your prescriber
Hydrochloride/Nepafenac) 1/0.5/0.1%**
*Prescribers are reminded that state law allows patients to receive medications from a pharmacy of their choice
**Representative formulation. Please contact us for an alternate formulation. Customizable within certain ranges.
Patient: DOB:
Age: Medication Allergies
M F Tel: Home
Work: Cell:
Address:
City: ST: Zip:
Oral Medications
*Prescribers are reminded that state law allows patients to receive medications from a pharmacy of their choice
**Representative formulation. Please contact us for an alternate formulation. Customizable within certain ranges.
Patient: DOB:
Age: M F Tel: Home
Work: Cell:
Address:
City: ST: Zip:
Please allow for 72 hours turnaround time (3 business days) before order will ship. Shipping (check one)
Incomplete orders may delay processing. FedEx Overnight FedEx 2 Day FedEx Ground
Acetyl-L-Carnitine MDV (200mg/ml)** 10ml EDTA (Disodium) MDV (150mg/ml) 100ml MIC MDV (25/50/50mg/ml) 30ml
Artesunate Lyophilized (60mg) 1 vial Glutathione MDV (200mg/ml) 30ml NAC (N-Acetylcysteine, 200mg/ml) PF** 30ml
Ascorbic Acid (non-corn source, 500/ml/mg) PF 50ml Glutathione Inhalation (200mg/ml) 2ml Nicotinamide Adenine Dinccleotide (NAD+, 40mg/ml) PF** 1ml
Ascorbic Acid (non-corn source, 500mg/ml) PF 100ml Hydrogen Peroxide (3%) PF** 30ml Phosphatidylcholine MDV (5%) 50ml
Calcium Chloride (10%) PF 10ml Menadione Sodium Bisulfate (Vit K3) (200mg/ml) PF** 10ml Phosphatidylcholine (PTC) MDV (3.5%) 50ml
Carnitine (L) (200mg/ml) PF 10ml Methylcobalamin (MB12) MDV (10mg/ml) 30ml Poly MVA IV 50ml
Chromium Chloride (4mcg/ml) PF 10ml Methylcobalamin (MB12) MDV (1mg/ml) 30ml Potassum Chloride (2meq/ml) PF^ 30ml
Chromium Chloride (200mcg/ml) PF 10ml Methylcobalamin (MB12) MDV (5mg/ml) 30ml Procaine (HCI) MDV (20mg/ml) 30ml
Co-Enzyme Q 10 (Ubiquinone) MDV (20mg/ml) 30ml Methylcobalamin (MB12, 25mg/ml) PF 1ml Pyridoxal 5 Phosphate MDV (100mg/ml) 30ml
Curcumin Emulsion MDV (10mg/ml) 10ml Methylcobalamin (MB12, 25mg/ml) PF 2ml Resveratrol MDV (10mg/ml) 10ml
Curcumin Emulsion MDV (10mg/ml) 30ml Methylcobalamin (MB12, 25mg/ml) PF 5ml Riboflavin MDV (50mg/ml)** 10ml
D3 Vitamin MDV (Cholecalciferol, 50,000u/ml) 10ml Methyltetrahydrofolate (5-MTHF) Lyophilized MDV (20mg) 1 vial Sermoreline/GHRP-6 (Lyophilized, 3mg/3mg) 1 vial
Dexpanthenol MDV (250mg/ml) 30ml MIC/Methycobalamin MDV (25/50/50/1mg/ml) 30ml Sermoreline/GHRP-2/GHRP-6 (Lyophilized, 3mg/3mg/3mg) 1 vial
Dichloroacetate (DCA) MDV (500mg/ml) 10ml MIC/Vit B Complex/MB12/Carnitine (L) MDV (25/50/50/1/100mg/ml) 30ml Taurine (L) MDV (50mg/ml) 30ml
DMSO USP (99%) PF 50ml MIC/Methycobalamin/Vit B6 MDV (25/50/50/5/30mg/ml) 30ml Other __________________________________
EDTA (Calcium, 300mg/ml) PF 30ml MIC/MB12/Vit B6/Carnitine MDV (25/50/50/5/50/50mg/ml) 30ml Other __________________________________
Amino Acids Infusion Bag (8.50%) 500ml Hyaluronidase (150u/ml) PF^ 2ml Mannitol (25%) PF^ 50ml
Arginine HCI (100mg/ml) 300ml Hydroxocobalamin MDV (1mg/ml)^ 30ml Selenium (40mcg/ml) PF 10ml
Bacteriostatic Water for Injection^ 30ml Leucovorin Calcium (50mg) PF^ 1 vial Sodium Bicarbonate (8.40%)^ 50ml
Calcium Gluconate (10%) PF 10ml Leucovorin Lyophilized (100mg) 1 vial Sterile Water for Injection 50ml
Cyanocobalamin (B12) MDV (1mg/ml) 30ml Lidocaine HCI (1%)^ 50ml Thiamine HCI (B1) MDV (100mg/ml)^ 2ml
Dexamethasone MDV (4mg/ml)^ 30ml Lidocaine HCI (2%)^ 50ml Vitamin B-Complex-100 MDV 30ml
Dextrose PF (50%)^ 50ml Magnesium Chloride MDV (200mg/ml) 50ml Zinc Sulfate (5mg/ml) 5ml
Prescriber Verification
I have reviewed my patient's medical record and determined the medication(s) / supplies ordered are medically necessary. I verify I have examined and diagnosed the patient as indicated above. I will comply
with state and federal documentation requirements by retaining a copy of this prescription in the patient's medical record. The prescription is to be dispensed as written unless otherwise instructed by me.
Payment Information
Credit Card Number: Expiration: CVC/Code: Billing Zip:
Please allow for 72-hours turnaround time (3 business days) before order will ship. Incomplete order submissions may delay processing.
Center/Clinic: Address:
Address:
Primary Contact: Patient Profile(s) or Block Schedule Attached: YES NO (circle one)
Email: # of Patients*:
*Prescribers are reminded that state law allows patients to receive medications from a pharmacy of their choice
Order Submission
THIS FORM CONSTITUTES A PRESCRIBERS ORDER/PRESCRIPTION WHEN SIGNED BY THE PRESRIBER.
# of Prescriptions
Payment Information
IF NO CREDIT CARD ON FILE AND YOU ARE NOT CURRENTLY BEING INVOICED, PLEASE SUBMIT THE FOLLOWING:
Pursuant to VA/OH/MO/VT law, only 1 medication is permitted per order form. Please use a new form for additional items.
WWW.IMPRIMISRX.COM
CALL 844.4.IMMYRX (844.446.6979)
FAX YOUR ORDERS TO 949.551.1950
Imprimis Pharmaceuticals, Inc.
12264 El Camino Real, Suite 350
San Diego, CA 92130
T: 858.704.4040 | F: 858.345.1745