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Phone: (877) 868-4110 Fax: (877) 868-4144
Prescribers and Staff
YOUR ONE-STOP SOLUTION
Our goal is to service all of the needs of your office and your patients.
• A member of our team will fax prescription and patient status updates throughout the prescription process• Prior authorizations to initiate treatment• Re-Authorization to prevent therapy interruption• Cost management•• No cost for delivery to patient home or your office• Injection training for self injectable medications at patient home or in your office• Disease and treatment education prior to therapy initiation• Ongoing side effects management• Customize patient monitoring• Refill reminders and coordination•• Retail prescriptions to ensure patients have ONE PHARMACY• Infusion & Compounding services available
AMERICAN SPECIALTY PHARMACY is able to assist you. We are a SpecialtyPharmacy with retail stores with the ability to fill ALL of your patient’s medications.
Attached you will find a Prescription Referral Form for use with specific chronicillnesses. If your patients also need other medications not listed, just send the
prescription along with it and we’ll take care of that too!
For more information please call or email:
Phone: (877) 868-4110 | Fax: (888) 294-9434 | Email: [email protected]
PLANO,TX | DENTON, TX | SAN ANTONIO | EL PASO, TX | TYLER, TX
www.AMERICANSPECIALTYPHARMACY.com
OUR PRODUCTS & SERVICES We are a full service pharmacy that specializes in:
Compounded & Specialty MedicationsDurable Medical Equipment (DME)
Nutritional SupplementationWorkers’ Compensation Prescriptions
Everyday Prescriptions
WE TAKE THE BURDEN OFF OF YOUOur customer service is second to none; provided by highly trained sta . We assist each patient throughout the entire
process. From contacting your insurance carrier to automatic re lls and overnight delivery.
We look forward to serving you and meeting all of your pharmacy needs.
www.AMERICANSPECIALTYPHARMACY.com
HOURS OF OPERATIONMon - Fri 9am until 7pm Sat & Sun 9am until 3pm
COMPLIMENTARY DELIVERYAll deliveries are delivered straight to
your door within 24 hours at no out-of-pocket cost to you.
AUTOMATIC REFILLSYour re lls are lled automatically based on
your prescription or physician’s approval. It is not necessary to reorder!
PLANO LOCATION2743 West 15th Street
Plano, TX 75075P: 877-868-4110 . F: 877-868-4144
At American Specialty Pharmacy, we use the latest technology with top quality ingredients to compound safe
and e ective customized medications. Our pharmacists are experts at compounding new, discontinued, back-ordered, or
unavailable medications to meet speci c patient needs.
We o er a full line of Professional Quality Vitamins, Nutritional Supplements, OTC Medications, Everyday
Prescriptions, Medical Equipment & Specialty Medications.
www.AMERICANSPECIALTYPHARMACY.com
PATIENT INFORMATION (Use this area or ĂƩĂĐŚ ƉĂƟĞnt demographiĐs)
Name: ______________________________________ Phone: __________________________ Phone 2: _________________________Home Address: ________________________________________ City: ____________________ State: _______ Zip: _______________ DOB: ______________ SSN: _________________ Sex: Male Female Height: ____________ Weight: _____________Lbs. Allergies: ________________________________________________________________________________________________________
INSURANCE INFORMATION (Use this area or ĂƩĂĐŚ Đopy of insuranĐĞ Đard(s)
Primary Name: _____________________________________ Secondary / RX: _____________________________________________Phone: ___________________________________________ Phone: ____________________________________________________ ID#: _______________________ Group: _______________ ID#: _________________________ Group: ______________________
MEDICAL ASSESSMENT (Use this area or ĂƩĂĐh paƟent labs and other authorizĂƟŽŶ ŝŶĨŽƌŵĂƟŽŶͿ
Primary Diagnosis: ___________________________________ Secondary / Other Diagnosis: ____________________________________ICD9 Code: _________________________________ ICD9 Code: ______________________________________ Previous Treatment(s): _________________________________________ Outcome: __________________________________________
PRESCRIPTION INFORMATION *(Use this area or ĂƩĂĐŚ Đopy of RX(s)
Prescriber Name: _____________________________________________ NPI#: ____________________________________ Address: _________________________________ City: __________________________ State: _________ Zip: _________ Phone: ______________________________ Fax: ______________________________ Email: _______________________________________ Oĸce Contact: __________________________________________
HIVFRMVS.12
Epivir Epzicom Fuzeon Intelence Invirase
ƉƟǀƵƐ Atripla Combivir Crixivan Emtriva
Isentress Kaletra Lexiva Norvir Prezista
Rescriptor Retrovir Rayataz Selzentry ^ƵƐƟǀĂ
Trizivir Truvada Videx EC Viracept Viramune
Viread Zerit Ziagen Other: _______________ Other: _______________ Other: _______________
HIV / INFECTIOUS DISEASEWƌĞƐĐƌŝƉƟŽŶ Form
Dose / Strength: Sig / ŝƌĞĐƟŽŶƐ ReĮůl(s): ____________ YƵĂŶƟƚLJ ____________ Date: _______________ Prescriber Signature: ___________________________________________________
^ĞůĞĐƚ MediĐĂƟŽŶ / Write in other(s)
This is a list of the most common Specialty HIV / /ŶĨĞĐƟŽƵƐ Disease medicaƟŽŶƐ American Specialty Pharmacy is available to Įůů all of your ƉĂƟĞŶƚƐ ƉƌĞƐĐƌŝƉƟŽŶ needs. Please include any other medicaƟŽŶƐ your ƉĂƟĞŶƚ needs including IV DĞĚŝĐĂƟŽŶƐ
PRESCRIBER INFORMATION
Treating Patients SpecialShip to: PaƟent Home MD KĸĐe
/ŶũĞĐƟŽŶdƌĂŝŶŝŶŐ DKĸĐĞAmerican Specialty to Arrange
FAX TO: (888) 294-9434
CALL:(877)753-6877 FAX:(888)294-9434 EMAIL: [email protected]
Today’s Date
PLEASE ATTACH COPIES OF PATIENT’S INSURANCE CARDS
MALE HRT REFERRAL FORM
PRESCRIPTION
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Prescriber’s Signature;ƐŝŐŶĂƚƵƌĞƌĞƋƵŝƌĞĚEK^dDW^ͿͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺĂƚĞͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ
&ĂdžĐŽŵƉůĞƚĞĚĨŽƌŵƚŽDZ/E^W/>dzW,ZDzat 888-966-0188
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ͺͺͺͺ ϬϮйϱй
CREAM, GEL & ETC - QTY: 30gm (Thrity Grams)ͲWƌĞŐŶĞŶŽůŽŶĞƌĞĂŵͲdĞƐƚŽƐƚĞƌŽŶĞƌĞĂŵͲdĞƐƚŽƐƚĞƌŽŶĞ,ƌĞĂŵͲ,WƌĞŐŶĞŶŽůŽŶĞϭϬйϭϬй ͲWĂƉĂǀĞƌŝŶĞϯϬŵŐŵůнWŚĞŶƚŽůĂŵŝŶĞϮŵŐŵůнůƉƌŽƐƚĂĚŝůϰϬϬŵĐŐŵů;'ĞůͿ ͲdĞƐƚŽƐƚĞƌŽŶĞWƌŽŐĞƐƚĞƌŽŶĞϮŵŐϭϬϬŵŐ ^ŝŐͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺZĞĮůůƐͺͺͺͺCREAM, GEL & ETC - QTY: 60ml (Sixty Milliliters)Ͳ,Ăŝƌ>ŽƐƐ&ŽƌŵƵůĂ^ƉƌĂLJ;&ŝŶĂƐƚĞƌŝĚĞDŝŶŽdžŝĚŝůͿ
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^ŝŐͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺZĞĮůůƐͺͺͺͺ
INJECTABLE - QTY: 10ml (Ten Milliliters)ͲdƌŝƉƚŽƌĞůŝŶĐĞƚĂƚĞ ͲdĞƐƚŽƐƚĞƌŽŶĞLJƉŝŽŶĂƚĞͲdĞƐƚŽƐƚĞƌŽŶĞLJƉWƌŽƉϳϬйϯϬй
COMPOUNDED INTRACAVERNOSAL - QTY: 10ml (Ten Milliliters)ͲWĂƉĂǀĞƌŝŶĞϮϴϱŵŐŵůнWŚĞŶƚŽůĂŵŝŶĞϭŵŐŵůнůƉƌŽƐƚĂĚŝůϱϬŵĐŐŵůͲWĂƉĂǀĞƌŝŶĞϮϬŵŐŵůнWŚĞŶƚŽůĂŵŝŶĞϮŵŐŵůнůƉƌŽƐƚĂĚŝůϯϬŵĐŐŵůͲWĂƉĂǀĞƌŝŶĞϱϴϴŵŐŵůнWŚĞŶƚŽůĂŵŝŶĞϬϱϴϴŵŐŵůнůƉƌŽƐƚĂĚŝůϭϳϲϰŵĐŐŵůͲWĂƉĂǀĞƌŝŶĞϮŵŐŵůнůƉƌŽƐƚĂĚŝůϯϬŵĐŐŵů
ADDITIONAL NOTES:
^LJƌ ͺͺͺͺͺͺ^ŝŐͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺZĞĮůůƐͺͺͺͺͺ^ŝŐͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺZĞĮůůƐͺͺͺͺͺ^ŝŐͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺZĞĮůůƐͺͺͺͺͺ
ϬϭŵŐŵůWƌĞĮůůĞĚϮϬϬŵŐŵůͺͺͺͺŵŐŵůϮϬϬŵŐŵů
^ŝŐͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺZĞĮůůͺͺͺͺ^ŝŐͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺZĞĮůůͺͺͺͺ^ŝŐͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺZĞĮůůͺͺͺͺ^ŝŐͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺZĞĮůůͺͺͺͺ
^ŝŐͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺYdz ͺͺͺͺͺZĞĮůůƐͺͺͺͺͺ
PATIENT INFORMATION (Use this area or ĂƩĂĐŚ ƉĂƟent demographiĐs)
Name: ______________________________________ Phone: __________________________ Phone 2: _________________________Home Address: ________________________________________ City: ____________________ State: _______ Zip: _______________ DOB: ______________ SSN: _________________ Sex: Male Female Height: ____________ Weight: _____________Lbs. Allergies: ________________________________________________________________________________________________________
INSURANCE INFORMATION (Use this area or aƩĂĐŚ Đopy of insuranĐe Đard(s)
Primary Name: _____________________________________ Secondary / RX: _____________________________________________Phone: ___________________________________________ Phone: ____________________________________________________ ID#: _______________________ Group: _______________ ID#: _________________________ Group: ______________________
MEDICAL ASSESSMENT (Use this area or ĂƩĂĐŚ ƉĂƟent labs and other authorizaƟon informaƟon)
Primary Diagnosis: _________________________ ICD9 Code: ________________________ HCV RNA: _________________Secondary Diagnosis: _______________________ ICD9 Code: ________________________ Hemoglobin: ______________ Genotype: ______ Subtype: ______ Relapsed ParƟal Response Null Response Hematocrit: _______________ Liver Biopsy Date: ___________ Result of Biopsy: __________________________________ ALT: _____________________ Previous Treatment: ____________________________________________________________ AST: _____________________
PRESCRIPTION INFORMATION *(Use this area or ĂƩĂĐŚ Đopy of RX(s)
PEGASYS® Pre-Filled Convenience Pack 180mcg (0.5mL) Sub-Q QW Other: ____________________________________
Qty: ______ ReĮůů: ______ month(s)
PEG–INTRON® Kg (Lbs) Redipen Vials <40 (<88) Inject 50mcg (0.5mL) Sub-Q QW 40-50 (89-110) Inject 64mcg (0.4mL) Sub-Q QW
51-60 (111-132) Inject 80mcg (0.5mL) Sub-Q QW 61-75 (133-165) Inject 96mcg (0.4mL) Sub-Q QW 76-85(166-187) Inject 120mcg (0.5mL) Sub-Q QW
>85 (>187) Inject 150mcg (0.5mL) Sub-Q QW Qty: __________ ReĮůů: _______ Month(s)
INFERGEN® 9mcg Sub-Q TIW 15mcg Sub-Q TIW 9mcg Sub-Q QD 15mcg Sub-Q QD Other: _______________________________
Qty: _____ ReĮůů: _______Month(s)
RIBAVIRIN 200mg600mg PO QD: 200mg-QAM 400mg-QPM Qty: 84 800mg PO QD: 400mg-QAM 400mg-QPM Qty: 112 1000mg PO QD: 400mg-QAM 600mg-QPM Qty: 140 1200mg PO QD: 600mg-QAM 600mg-QPM Qty: 168 1400mg PO QD: 600mg-QAM 800mg-QPM Qty: 196 Other PO QD: _______QAM / ______QPM Qty: ___
ReĮůů:_______ Month(s)
RIBAPAK® 800mg PO QD: (1)400mg QAM – (1)400mg QPM 1000mg PO QD: (1)400mg QAM – (1)600mg QPM 1200mg PO QD: (1)600mg QAM – (1)600mg QPM 1400mg PO QD: (1)600mg QAM – (1)600mg + (1)200mg QPM
ReĮůů: _____ Month(s) DO NOT SUBSTITUTE / D.A.W.
INCIVEK® 375mg tabs 750mg PO TID: (2)375mg tabs
Q7-9hrs w/ ĨĂƩLJ food for 12 weeks with interferon/ribavirin Qty: 168 tablets ReĮůů: _______
VICTRELIS® 200mg caps 800mg PO TID: (4)200mg caps
Q7-9hrs w/ food. Begin day 29 of interferon/ribavirin Qty: 336 ReĮůů: _______
HUMIRA® Humira Pen Starter Pack 40mg/pen, 6/box Other: _____________________________________
Sig: Inject 160mg (4-pens) sub-q iniƟal dose then 80mg (2-pens)
sub-q on day 15 then 40mg (1-pen) sub-q QOW Inject 80mg (2-pens) sub-q QD for 2 days ŝŶŝƟĂl dose, then
80mg(2-pens) sub-q day 15, then 40mg (1-pen) sub-q QOW 40mg sub-q every 2 weeks 40mg sub-q every week Other: _________________________________ QuanƟty: _______ ReĮůů: _______
CIMZIA® 200mg single dose vials 2/box Qty: ____ boxes 200mg single use PFS 2/box Qty: ____ boxes
Sig: IniƟal dose: 400mg sub-q at week 0, 2, and 4 Maintenance: 400mg sub-q every 4 weeks ReĮůů: _________
REMICADE® Single use 100mg vial #____vials Excel sodium chloride 250ml bag #____bags Sterile water / injecƟon 10ml/vial #____vials Normal saline ŇƵƐŚ 10mL/PFS #____syringes Epipen® Benadryl® 50mg vial PRN
DirecƟŽŶƐ: __________________________________ ReĮůů: __________
Aranesp® Epogen® Neulasta® Neupogen® WƌŽĐƌŝƚΠ
Dose: ___________________ Sig: ________________________ Qty: ______ ReĮůů: ______
HCVFRMVS.912
HEPATITIS / CROHNSWƌĞƐĐƌŝƉƟŽŶ Form
WƌĞƐĐƌŝďĞƌ Signature: _________________________________ Date: _________
PRESCRIBER INFORMATION
Prescriber Name: _____________________________________________ NPI#: ____________________________________ Address: _________________________________ City: __________________________ State: _________ Zip: _________ Phone: ______________________________ Fax: ______________________________ Email: _______________________________________ Oĸce Contact: __________________________________________
FAX TO: (888)294-9434
Treating Patients Special
HEPATITIS B ORAL THERAPIES Baraclude 1 Tablet po QD
0.5mg 1.0mg
Epivir HBV 100mg __________
Hepsara 10mg _____________Tyzeka 600mg _____________Viread 300mg _____________
Ship to: PaƟent Home MD KĸĐe
/ŶũĞĐƟŽŶdƌĂŝŶŝŶŐ DKĸĐĞAmerican Specialty to Arrange
CALL:(877)753-6877 FAX:(888)294-9434 EMAIL: [email protected]
Today’s Date
PLEASE ATTACH COPIES OF PATIENT’S INSURANCE CARDS
hCG REFERRAL FORM
PRESCRIPTION
LJƐŝŐŶŝŶŐƚŚŝƐĨŽƌŵĂŶĚƵƟůŝnjŝŶŐŽƵƌƐĞƌǀŝĐĞƐLJŽƵĂƌĞĂƵƚŚŽƌŝnjŝŶŐŵĞƌŝĐĂŶĂŶĚŝƚ ƐĞŵƉůŽLJĞĞƐƚŽƐĞƌǀĞĂƐLJŽƵƌƉƌŝŽƌĂƵƚŚŽƌŝnjĂƟŽŶĚĞƐŝŐŶĂƚĞĚĂŐĞŶƚŝŶĚĞĂůŝŶŐǁŝƚŚŵĞĚŝĐĂůĂŶĚƉƌĞƐĐƌŝƉƟŽŶŝŶƐƵƌĂŶĐĞĐŽŵƉĂŶŝĞƐ
Prescriber’s Signature;ƐŝŐŶĂƚƵƌĞƌĞƋƵŝƌĞĚEK^dDW^ͿͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺĂƚĞͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺIMPORTANCE NOTICE: dŚŝƐĨĂdžŝƐŝŶƚĞŶĚĞĚƚŽďĞĚĞůŝǀĞƌĞĚŽŶůLJƚŽƚŚĞŶĂŵĞĚĂĚĚƌĞƐƐĞĞ/ƚĐŽŶƚĂŝŶƐŵĂƚĞƌŝĂůƚŚĂƚŝƐĐŽŶĮĚĞŶƟĂůƉƌŝǀŝůĞŐĞĚƉƌŽƉƌŝĞƚĂƌLJŽƌĞdžĞŵƉƚĨƌŽŵĚŝƐĐůŽƐƵƌĞƵŶĚĞƌ
ĂƉƉůŝĐĂďůĞůĂǁ/ĨLJŽƵĂƌĞŶŽƚƚŚĞŶĂŵĞĚĂĚĚƌĞƐƐĞĞLJŽƵƐŚŽƵůĚŶŽƚĚŝƐƐĞŵŝŶĂƚĞĚŝƐƚƌŝďƵƚĞŽƌĐŽƉLJƚŚŝƐĨĂdžWůĞĂƐĞŶŽƟĨLJƚŚĞƐĞŶĚĞƌŝŵŵĞĚŝĂƚĞůLJŝĨLJŽƵŚĂǀĞƌĞĐĞŝǀĞĚƚŚŝƐĚŽĐƵŵĞŶƚŝŶĞƌƌŽƌĂŶĚƚŚĞŶĚĞƐƚƌŽLJƚŚŝƐĚŽĐƵŵĞŶƚŝŵŵĞĚŝĂƚĞůLJ
&ĂdžĐŽŵƉůĞƚĞĚĨŽƌŵƚŽDZ/E^W/>dzW,ZDzat 888-966-0188
WĂƟĞŶƚEĂŵĞͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺKͺͺͺͺͺͺͺͺͺͺͺͺtĞŝŐŚƚͺͺͺͺͺͺͺDĂůĞ&ĞŵĂůĞ^ƚƌĞĞƚĚĚƌĞƐƐͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺƉƚηͺͺͺͺͺͺͺͺͺŝƚLJͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ^ƚĂƚĞͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺŝƉͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺĂLJƟŵĞWŚͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺǀĞŶŝŶŐWŚͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺĞůůͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺŵĂŝůͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺůůĞƌŐŝĞƐͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ
&ŝƌƐƚ DŝĚĚůĞ >ĂƐƚ
WƌĞƐĐƌŝďĞƌ ƐEĂŵĞͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺKĸĐĞŽŶƚĂĐƚͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ^ƚƌĞĞƚĚĚƌĞƐƐͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ^ƵŝƚĞηͺͺͺͺͺͺͺͺͺŝƚLJͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ^ƚĂƚĞͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺŝƉͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺdĞůͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ&ĂdžͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺŵĂŝůͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ>ŝĐĞŶƐĞηͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺEW/ηͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺhW/Eηͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺηͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ
EtWd/EdhZZEdWd/Ed
Sublingual Drops: *Administer sublingually 4 drops a day Ś'ϭϬϬϬϬ/h;ϭϬŵůͿ Ś'ϱϬϬϬ/h;ϱŵůͿĂLJƐ^ƵƉƉůLJ 30 40ZĞĮůůƐϭ;KŶĞͿϮ;dǁŽͿϯ;dŚƌĞĞͿ
Nasal Spray (not available for hypogonadism) *Administer one spray per nostril daily Ś'ϭϮϱϬϬ/h;ƚLJƉŝĐĂůůLJϭϬŵůͿ Ś'ϲϮϱϬ/h;ƚLJƉŝĐĂůůLJϱŵůͿĂLJƐ^ƵƉƉůLJ 30 40ZĞĮůůƐϭ;KŶĞͿϮ;dǁŽͿϯ;dŚƌĞĞͿ
Injectable: *Administer daily or bi-weekly Ś'ϭϬϬϬϬ/h;ϭϬŵůͿŚ'ϱϬϬϬ/h;ϱŵůͿKƉƟŽŶĂůĚĚŝƟǀĞƐ DĞƚŚLJůĐŽďĂůĂŵŝŶϱϬϬ;ŵĐŐŵůͿDĞƚŚLJůĐŽďĂůĂŵŝŶϭϬϬϬ;ŵĐŐŵůͿDĞƚŚLJůĐŽďĂůĂŵŝŶϰϬϬϬ;ŵĐŐŵůͿĂLJƐ^ƵƉƉůLJ 30 40ZĞĮůůƐϭ;KŶĞͿϮ;dǁŽͿϯ;dŚƌĞĞͿ
Slim Shots: *Inject as directed sŝƚĂŵŝŶͲϭϮ D//ŶũĞĐƟŽŶƐ ĚĞŶŽƐŝŶĞŽƌDĞƚĂďŽůŝƐŵŽŽƐƚĞƌ/ŶũĞĐƟŽŶ ϳ<ĞƚŽ,ϮϱŵŐ;KdͿ WŚĞŶƚĞƌŵŝŶĞŚƌŽŵŝƵŵWŝĐŽůŝŶĂƚĞ,LJĚƌŽdžƚƌLJƉƚŽƉŚĂŶ;>ͲϱͿ^ZĂƉƐƵůĞƐϯϳϱŵŐϯϬϬŵĐŐϭϬϬŵŐ ŽYϭϬϭϬϬŵŐ;KdͿ dŚLJƌŽ^ƵƉƉŽƌƚ;KdͿ ŝŐĞƐƟǀĞŶnjLJŵĞhůƚƌĂ;KdͿ ƉƉůĞŝĚĞƌsŝŶĞŐĂƌ;KdͿ
ADDITIONAL NOTES:
ϮϳϰϯtĞƐƚϭϱƚŚ^ƚƌĞĞƚWůĂŶŽdyϳϱϬϳϱWϴϳϳͲϳϱϯͲϲϴϳϳ&ĂdžϴϴϴͲϵϲϲͲϬϭϴϴ
Today’s Date
PLEASE ATTACH COPIES OF PATIENT’S INSURANCE CARDS
COMPOUNDED INTRACAVERNOSAL
PRESCRIPTION
LJƐŝŐŶŝŶŐƚŚŝƐĨŽƌŵĂŶĚƵƟůŝnjŝŶŐŽƵƌƐĞƌǀŝĐĞƐLJŽƵĂƌĞĂƵƚŚŽƌŝnjŝŶŐŵĞƌŝĐĂŶĂŶĚŝƚ ƐĞŵƉůŽLJĞĞƐƚŽƐĞƌǀĞĂƐLJŽƵƌƉƌŝŽƌĂƵƚŚŽƌŝnjĂƟŽŶĚĞƐŝŐŶĂƚĞĚĂŐĞŶƚŝŶĚĞĂůŝŶŐǁŝƚŚŵĞĚŝĐĂůĂŶĚƉƌĞƐĐƌŝƉƟŽŶŝŶƐƵƌĂŶĐĞĐŽŵƉĂŶŝĞƐ
Prescriber’s Signature;ƐŝŐŶĂƚƵƌĞƌĞƋƵŝƌĞĚEK^dDW^ͿͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺĂƚĞͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ
&ĂdžĐŽŵƉůĞƚĞĚĨŽƌŵƚŽDZ/E^W/>dzW,ZDzat 888-966-0188
WĂƟĞŶƚEĂŵĞͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺKͺͺͺͺͺͺͺͺͺͺͺͺtĞŝŐŚƚͺͺͺͺͺͺͺDĂůĞ&ĞŵĂůĞ^ƚƌĞĞƚĚĚƌĞƐƐͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺƉƚηͺͺͺͺͺͺͺͺͺŝƚLJͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ^ƚĂƚĞͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺŝƉͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺĂLJƟŵĞWŚͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺǀĞŶŝŶŐWŚͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺĞůůͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺŵĂŝůͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺůůĞƌŐŝĞƐͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ
&ŝƌƐƚ DŝĚĚůĞ >ĂƐƚ
WƌĞƐĐƌŝďĞƌ ƐEĂŵĞͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺKĸĐĞŽŶƚĂĐƚͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ^ƚƌĞĞƚĚĚƌĞƐƐͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ^ƵŝƚĞηͺͺͺͺͺͺͺͺͺŝƚLJͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ^ƚĂƚĞͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺŝƉͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺdĞůͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ&ĂdžͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺŵĂŝůͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ>ŝĐĞŶƐĞηͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺEW/ηͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺhW/Eηͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺηͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ
EtWd/EdhZZEdWd/Ed
MIX: - ůƉƌŽƐƚĂĚŝů ϭϬŵĐŐŵů ϮϬŵĐŐŵů Ydz ϱŵů;&ŝǀĞDŝůůŝůŝƚĞƌƐͿ^ŝŐͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺZĞĮůůƐͺͺͺͺBI-MIX:ͲWĂƉĂǀĞƌŝŶĞϯϬŵŐнWŚĞŶƚŽůĂŵŝŶĞϭŵŐŵů Ydz ϱŵů;&ŝǀĞDŝůůŝůŝƚĞƌƐͿͲWĂƉĂǀĞƌŝŶĞϮŵŐŵůнůƉƌŽƐƚĂĚŝůϯϬŵĐŐŵů Ydz ϭϬŵů;dĞŶDŝůůŝůŝƚĞƌƐͿ^ŝŐͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺZĞĮůůƐͺͺͺͺTRI-MIX: ͲWĂƉĂǀĞƌŝŶĞϯϬŵŐнWŚĞŶƚŽůĂŵŝŶĞϬϮϱŵŐнůƉƌŽƐƚĂĚŝůϭϬŵĐŐŵů Ydz ϱŵů;&ŝǀĞDŝůůŝůŝƚĞƌƐͿͲWĂƉĂǀĞƌŝŶĞϮϴϱŵŐŵůнWŚĞŶƚŽůĂŵŝŶĞϭŵŐŵůнůƉƌŽƐƚĂĚŝůϱϬŵĐŐŵů Ydz ϭϬŵů;dĞŶDŝůůŝůŝƚĞƌƐͿͲWĂƉĂǀĞƌŝŶĞϮϬŵŐŵůнWŚĞŶƚŽůĂŵŝŶĞϮŵŐŵůнůƉƌŽƐƚĂĚŝůϯϬŵĐŐŵů Ydz ϭϬŵů;dĞŶDŝůůŝůŝƚĞƌƐͿͲWĂƉĂǀĞƌŝŶĞϱϴϴŵŐŵůнWŚĞŶƚŽůĂŵŝŶĞϬϱϴϴŵŐŵůнůƉƌŽƐƚĂĚŝůϭϳϲϰŵĐŐŵů Ydz ϭϬŵů;dĞŶDŝůůŝůŝƚĞƌƐͿͲWĂƉĂǀĞƌŝŶĞϯϬŵŐŵůнWŚĞŶƚŽůĂŵŝŶĞϮŵŐŵůнůƉƌŽƐƚĂĚŝůϰϬϬŵĐŐŵů Ydz ϯϬŐŵ;dŚŝƌƚLJ'ƌĂŵƐͿͲWƌŽƐƚĂŐůĂŶĚŝŶϭϭϬђŐнWĂƉĂǀĞƌŝŶĞŚLJĚƌŽĐŚůŽƌŝĚĞϯϬŵŐнWŚĞŶƚŽůĂŵŝŶĞŵĞƐLJůĂƚĞϱϬϬђŐYdz ϭŵů;KŶĞDŝůůŝůŝƚĞƌƐͿ^ŝŐͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺZĞĮůůƐͺͺͺͺQUATRO-MIX: ͲWĂƉĂǀĞƌŝŶĞϮϬŵŐнWŚĞŶƚŽůĂŵŝŶĞϭŵŐнůƉƌŽƐƚĂĚŝůϭϬŵĐŐнƚƌŽƉŝŶĞϬϭŵŐŵů Ydz ϱŵů;&ŝǀĞDŝůůŝůŝƚĞƌƐͿ^ŝŐͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺZĞĮůůƐͺͺͺͺ
ϮϳϰϯtĞƐƚϭϱƚŚ^ƚƌĞĞƚWůĂŶŽdyϳϱϬϳϱWϴϳϳͲϳϱϯͲϲϴϳϳ&ĂdžϴϴϴͲϵϲϲͲϬϭϴϴ
/DWKZdEEKd/dŚŝƐĨĂdžŝƐŝŶƚĞŶĚĞĚƚŽďĞĚĞůŝǀĞƌĞĚŽŶůLJƚŽƚŚĞŶĂŵĞĚĂĚĚƌĞƐƐĞĞ/ƚĐŽŶƚĂŝŶƐŵĂƚĞƌŝĂůƚŚĂƚŝƐĐŽŶĮĚĞŶƟĂůƉƌŝǀŝůĞŐĞĚƉƌŽƉƌŝĞƚĂƌLJŽƌĞdžĞŵƉƚĨƌŽŵĚŝƐĐůŽƐƵƌĞƵŶĚĞƌĂƉƉůŝĐĂďůĞůĂǁ/ĨLJŽƵĂƌĞŶŽƚƚŚĞŶĂŵĞĚĂĚĚƌĞƐƐĞĞLJŽƵƐŚŽƵůĚŶŽƚĚŝƐƐĞŵŝŶĂƚĞĚŝƐƚƌŝďƵƚĞŽƌĐŽƉLJƚŚŝƐĨĂdžWůĞĂƐĞŶŽƟĨLJƚŚĞƐĞŶĚĞƌŝŵŵĞĚŝĂƚĞůLJŝĨLJŽƵŚĂǀĞƌĞĐĞŝǀĞĚƚŚŝƐĚŽĐƵŵĞŶƚŝŶĞƌƌŽƌĂŶĚƚŚĞŶĚĞƐƚƌŽLJƚŚŝƐĚŽĐƵŵĞŶƚŝŵŵĞĚŝĂƚĞůLJ DĞĚŝĐĂƌĞĂŶĚDĞĚŝĐĂŝĚŽƌĂŶŽƚŚĞƌƐƚĂƚĞĨƵŶĚĞĚƉƌŽŐƌĂŵǁŝůůŶŽƚĐŽǀĞƌĂďŽǀĞŵĞŶƟŽŶĞĚĐŽŵƉŽƵŶĚƐŽͲƉĂLJŵĞŶƚƐĚƵĞĂƚĚŝƐƉĞŶƐŝŶŐŽĨƚŚĞŵĞĚŝĐĂƟŽŶ
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