Writing Perscriptions

 

Click here for a printable version of “How to Write for Compounded Prescriptions”

 

Rx     Patient: _____________________________

             Date:____________________

             Address: ____________________________

             City/St/Zip: _______________________

             Home phone:____________________

             Work Phone: _______________________

             Allergies: ____________________________

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 _____________________________________________ 

 

Physician (print): ________________________________

Physician phone: ________________________________

Physician signature: ______________________________

 

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