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Sig. ______________________________________ Donor ID/ Name: Donor D.O.B: Gonal F 300IU Pen 450IU Pen 900IU Pen 75IU 450IU M-D 1050IU M-D ________ Re�ills ________ Re�ills ________ Re�ills ________ Re�ills ________ Re�ills Sig. ______________________________________ _______ Vials Follistim AQ 300IU 600IU 900IU Sig. ______________________________________ _______ Car. Follistim Pen (if cart. ordered) _______ # Menopur 75IU vial Sig. ______________________________________ _______ Vials Cetrotide 0.25mg Sig. ______________________________________ _______ Vials Ganirelix Acetate (Antagon) 250ug/0.5ml Sig. ______________________________________ _______ Syr. ________ Re�ills Leuprolide 2 week kit Extra Lupron syringes Sig. ___________________ ___________________ _______ Kits ________ Re�ills Lupron Microdose (cmpd) ___ ___ mcg/_______ml ________ml Vial Sig. ______________________________________ _______ Vials/Syr. ________ Re�ills 4mg/0.8ml ________ Re�ills ________ Re�ills ________ Re�ills Progesterone in Oil 50mg 100mg /ml 10ml vial Sesame Oil Ethyl Oleate Sig. ______________________________________ _______ Vials ________ Re�ills Progesterone Vaginal Suppositories (cmpd) 50mg 100mg 200mg Sig. ______________________________________ _______ Supp. ________ Re�ills Progesterone Micronized Vaginal Capsules 200mg (cmpd) Sig. ______________________________________ _______ Caps. ________ Re�ills Crinone 8% gel (15 apps./box) Sig. ______________________________________ _______ Apps ________ Re�ills Endometrin 100mg Sig. ______________________________________ _______ Boxes ________ Re�ills Baby Aspirin 81mg Sig. ______________________________________ _______ Tabs ________ Re�ills Clomiphene Citrate 50mg Sig. ______________________________________ _______ Tabs ________ Re�ills Doxycycline 100mg Sig. ______________________________________ _______ Caps ________ Re�ills Estrace 1mg 2mg Sig. ______________________________________ _______ Tabs ________ Re�ills Medrol 4mg 16mg Sig. ______________________________________ _______ Tabs ________ Re�ills Provera Tabs 10mg Sig. ______________________________________ _______ Tabs ________ Re�ills Vivelle dot / Miniville 0.1mg 0.05mg Sig. ______________________________________ _______ Patches ________ Re�ills Zithromax 250mg Sig. ______________________________________ _______ Tabs ________ Re�ills Lovenox 40mg PFS Sig. ______________________________________ _______ Syr. ________ Re�ills Dostinex (Cabergoline) 0.5mg Sig. ______________________________________ _______ Tabs ________ Re�ills Heparin 5,000 units/ml Sig. ______________________________________ _______ Vials ________ Re�ills Des ogen 28 day Sig. ______________________________________ _______ Pk ________ Re�ills Sig. ______________________________________ _______ Qty ________ Re�ills Sig. ______________________________________ _______ Box ________ Re�ills Sig. ______________________________________ _______ Qty ________ Re�ills Sig. ______________________________________ _______ Qty ________ Re�ills Sharps Package – (Sterile sponges, alcohol swabs, sharps container ) 3ml syringe ________ # ________ Re�ills Submitted By: __________________________________________________________ 18g 1 ½” 3cc syringe and needle ________ # ________ Re�ills 30g ½” needle ________ # ________ Re�ills 25g 5/8” needle ________ # ________ Re�ills Anticipated Start Date: ______ /_______ /________ Today’s Date: ______ /_______ /_________ 27g ½” needle ________ # ________ Re�ills 22g 1 ½” needle ________ # ________ Re�ills Physician’s Signature: __________________________________________________________, MD ____________________________________ ________# ________ Re�ills Interchange is mandated unless practitioner writes the words “NO SUBSTITUTION” in this space IVF ICSI IUI REC DON CRYO Allergies: Ship to: Of�ice Patient Synera Patches / Topical Patch F: 866.301.1364 P: 855.255.5005 Phone #: Email: For Payment /Recipient Name: D.OB: Phone #: Lupron Trigger PFS (cmpd) 2mg/0.4ml Sig. ______________________________________ _______ Syr. Pregnyl 10,000IU Novarel 5,000IU vial Sig. ______________________________________ _______ Vials Ovidrel 250mg PFS Sig. ______________________________________ _______ PFS Saizen 5mg 8.8mg Sig. ______________________________________ _______ Vials ________ Re�ills _______ Qty ________ Re�ills 40 0.2 10
