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Patient Information:
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| Triple Mix: 30/1/10 |
Papaverine:30mg / Phentolamine:1mg / Alprostadil:10mcg / ml
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| Syringe Volume: |
______ml - Quantity:________ |
OR
| Custom Formula: |
Papaverine:___mg / Phentolamine:-___mg / Alprostadil:___mcg / ml
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| Volume: |
______ml Syringe OR ____ml Vial - Quantity:________ |
# of Refills: ________ / Refills authorized until: ______/______/_______
Signature: ___________________________________________________ Date: _________
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