Click Orange PRINT Icon & FAX to 630-859-0114
RX: Compounded 17-P Hydroxy Progesterone Caproate,
250mg/ml in Sesame Oil #5ml Vial
*** $80.00 5ml / $150.00 10ml ***
Patient will be contacted for payment prior to shipping.
Instructions: Inject 1ml weekly IM, as directed.
Quantity of Vials Prescribed: #_________ - Refills: ______
Syringes & Alcohol Wipes included
***The prescriber and patient understand that an FDA approved and manufactured form of this drug is available. The prescriber has determined that in the best clinical interest of the patient, a compounded form of this medication is being ordered instead of the manufactured product.***
Doctor Signature: _____________________________ Date: ______/______/_______
Patient Name:
|
|
Date of Birth:
|
|
Patient Phone:
|
|
Patient Address:
|
|
| City/State/ZIP: |
|
| Doctor Name: |
|
| Doctor Phone: |
|
| Doctor Address: |
|
| City/State/ZIP |
|
| DEA#: |
|
| License Number: |
|
SHIP TO:
|
Ship to MD office _____ Ship to Patient _____ |
Product costs do not include shipping and handling fees.
Shipping will be added prior to charging.
All information will be verified prior to processing.
All patient information is considered confidential and is to be released only to authorized personnel, as delineated by HIPAA.
|
Spider Design, Inc. Untangling the web, one site at a time.
