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Suggested Dyclonine Order Form |
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Click Orange PRINT Icon & FAX to 630-859-0114
Drug Name:
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Compounded Dyclonine Dental Preparation
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Strength (Please Circle):
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0.5% (regular strength) ~ 1% (double strength)
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| Volume (Please Circle): |
120ml ~ 240ml ~ 480ml ~ 960ml (2 x 480ml)
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| Flavor (Please Circle): |
Light Mint ~ Cinnamon ~ Light Vanilla ~ Other |
Prescriber Signature: _____________________________ Date: ___/___/____
| Doctor Name: |
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| Phone: |
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| Address: |
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| City/State/ZIP |
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| DEA/License#: |
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Credit Card #:
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Expiration: ___/____ -- -- -- -- Security Code: ____ |
| Signature: |
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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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