How to Write for a Compounded Prescription

 

Rx    Name: ______________________
          Date: _______________________

           Pt. Phone: ___________________

    Compounded Medication 
    (please indicate it's a compounded prescription)

Generic name of active ingredient(s) / Strength or Dose (i.e. % or mg)

____________________________________________________

   

Dosage Form (i.e., Transdermal, suppository, capsule, troche)

_______________________________________________

 

Quantity _____________________

 

Sig ____________________________________________________

_______________________________________________________

 

Doctor name (print): ________________

Doctor phone: ___________________

Doctor: ______________________

 

 Please contact our pharmacy for specific questions regarding formulations: 1.866.883.8868 (toll free)

Click here to print this form

 

 

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Healthway Pharmacy
1008 N. Saginaw St.
St. Charles, Michigan 48655

989-865-9971 - Phone
989-865-6216 - Fax
1-800-742-7527 - Toll Free

Healthway Compounding Pharmacy
2544 McLeod Dr., N.
Saginaw, Michigan 48604

989-791-1691 - Phone
989-791-4603 - Fax
1-866-883-8868 - Toll Free