Acology  Prescription  Compounding  Center

131 Del Prado S.               Ph: (239) 573-2424   (800) 240-8958

Cape Coral, Florida   33990         www .Rx2u.com       Fax: (239) 573-2426

CONFIRMATION   OF  COMPOUNDED  PRESCRIPTION   ORDER

Patient Information

 

Name__________________________________________   Birth Date________________

 

Address________________________________________   Telephone________________

 

City______________________________      State____________    Zip________________

 

Medication Needed  (check all that apply): 

*          *          *          *          *          *          *          *          *          *          *          *          *    

□   Estriol .5mg/.5ml  Insert one applicatorfull vaginally at bedtime for 14 days then every

      other day.           REFILL:  ______times or ______PRN for 1 year

_________________________________________________________________________

q       Bi-Est 80/20          □    Tri-Est 80/10/10

       ______total mg   □Topical   □Oral (oil cap)  □Sub Lingual Drop   □Lozenge

Times per Day:  □ QD  □ BID             □ TID               □ QID              □________

REFILL:  ______times or ______PRN for 1 year

_________________________________________________________________________

□  Progesterone Micro _____mg □Topical   □Oral (oil cap)  □SubLingual Drop  □Lozenge

Times per Day:  □ QD  □ BID             □ TID               □ QID              □ ________

                     REFILL:  ______times or ______PRN for 1 year

 

q       Testosterone Micro (female) Topical (PLO)________mg/0.1ml To apply 0.1ml per dose

□    Testosterone Micro (female) ______mg   □Sub Lingual Drop   □Lozenge

Times per Day: □ QD               □ BID             □ TID               □ QID              □ _________

                     REFILL:  ______times or ______PRN for 6 months

 

q       Testosterone Micro (male) Topical____mg/dose

           □ Modified PLO base        □ Fast absorption alcohol base

□    Testosterone Micro (male) ______mg    □Sub Lingual Drop   □Lozenge

Times per Day: □ QD               □ BID             □ TID               □ QID              □ _________

                     REFILL:  ______times or ______PRN for 6 months

 

□    Combination of above (must be same dosage form and times per day)

       □  Estrogen     □ Progesterone    □ Testosterone

_________________________________________________________________________

 

Doctors Name ____________________DEA#_____________Telephone _______________  

Address__________________________City___________  State  __________  Zip   ______  

 

Doctor’s Signature_____________________________________   Date_______________