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Home > Alternative Treatments > Practitioner Pages > Suggested Trimix Order Form
Trimix FAX Order Print E-mail

Click Orange PRINT Icon & FAX to 630-859-0114

 

Doctor Name:
DEA/License #:
Address:
City/State/ZIP:
Phone:
FAX:


Patient Information:

Patient Name:
Patient Phone:
Address:
City/State/ZIP:
Phone:

 

Triple Mix: 30/1/10

Papaverine:30mg / Phentolamine:1mg / Alprostadil:10mcg / ml
Syringe Volume: ______ml   -   Quantity:________

OR

Custom Formula:

Papaverine:___mg / Phentolamine:-___mg / Alprostadil:___mcg / ml
Volume: ______ml Syringe OR ____ml Vial   -   Quantity:________

 

# of Refills: ________ / Refills authorized until: ______/______/_______

 

Signature: ___________________________________________________ Date: _________
 
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