TO: The
Compounder Pharmacy
340 Marshall, Unit 100 * Aurora, IL
60506
630-859-0333 FAX: 630-859-0114
Patient
Information
Patient
Name:
Date:
Address:
City,
State, ZIP:
Date of
Birth:
Telephone:
Suggested
Order for Liver & Thiamin
Injections
(Ref: Dale Humpherys)
(1) THIAMINE INJECTION
200 mg thiamine/ml, 30 ml
quantity=_____ SIG: Inject 1 ml IM
daily as directed
(2) LIVER EXTRACT
INJECTION 10 ml
quantity=_____
(Nutrients
in Liver) SIG: Inject 2 ml IM
weekly (0.5ml 4 times per week
on Mon Wed Fri Sun)
(3) Syringes and Needles
quantity=_____ SIG: For use with
thiamine and liver injections
Refills:_____________________
Prescriber Information
Name
(print)
(MD, DO,
other_______)
Signature
Address
City,
State, ZIP
Phone
FAX
License
Number
DEA Number
When appropriate, the pharmacist will
contact the doctor by telephone.
We stand behind everything you
purchase through our website with our 100% satisfaction guarantee.
If you are not delighted with anything you purchase from us, let us
know, and we'll arrange to refund your purchase price.
PLEASE NOTE: The Compounder ships only to addresses in the United States.
Disclaimer:
Any health related information is for educational purposes only.
None of the information provided here is to be construed as medical
advice. Before applying any therapy or use of herbs, you may want to
seek advice from your health care professional. The information on
our website should not be a substitute for physician evaluation or
treatment by a health care professional and is not intended to
provide or confirm a diagnosis.
