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Suggested 4-AP Order Form |
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Click Orange PRINT Icon & FAX to 630-859-0114
Please circle the correct 4-Aminopyridine strength:
5mg 10mg ____mg
Quantity of Capsules: #_________ - Refills: ______
Instructions: Start at 1 capsule daily and follow ramping instructions, unless instructed otherwise by prescriber.
Warning: Do not exceed prescribed amount.
Doctor Signature: _____________________________ Date: ___/___/____
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| Patient Address: |
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| Doctor Name: |
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| Doctor Phone: |
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| Doctor Address: |
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| City/State/ZIP |
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| DEA#: |
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| License Number: |
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Product costs do not include shipping and handling fees. Shipping will be added prior to charging.
Please print & FAX to 630-859-0114
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.
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