Writing 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)