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Vios-Compounding-Topical-Pain-Form

Vios Compounding Pharmacy provides a full line of compound medications, customized according to your physician's orders.

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Vios-Compounding-Topical-Pain-Form

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  1. TOPICAL PAIN PRESCRIPTION FORM 1 OF 3 Please fax completed form to (800) 537-5193 or call (800) 518-9831 31035 Schoolcraft Rd • Livonia, Michigan 48150 • vioscompounding.com PATIENT INFORMATION PLEASE FAX WITH PATIENT DEMOGRAPHIC SHEET & RX INSURANCE CARD NAME ALLERGIES DATE OF BIRTH PHONE ADDRESS CITY STATE ZIP MEDICATION / CONCENTRATION Gabapentin 5%, Amitriptyline 3%, Clonidine 0.2%, Lidocaine 5% SUPPLIED 100 gm 240 gm 360 gm SIG Apply 1 to 2 grams 3 to 4 times daily as directed. REFILLS ______ None NEUROPATHIC Gabapentin 5%, Amitriptyline 3%, Clonidine 0.2%, Lidocaine 5%, Ketamine 10% 100 gm 240 gm 360 gm Apply 1 to 2 grams 3 to 4 times daily as directed. ______ None Diclofenac 3%, Baclofen 2%, Lidocaine 5% 100 gm 240 gm 360 gm Apply 1 to 2 grams 3 to 4 times daily as directed. ______ None Diclofenac 3%, Baclofen 2%, Lidocaine 5%, Ketamine 5% 100 gm 240 gm 360 gm Apply 1 to 2 grams 3 to 4 times daily as directed. ______ None Ketoprofen 15%, Lidocaine 10% 100 gm 240 gm 360 gm Apply 1 to 2 grams 3 to 4 times daily as directed. ______ None ANTI-INFLAMMATORY Diclofenac 3%, Baclofen 2%, Magnesium Chloride 2% 100 gm 240 gm 360 gm Apply 1 to 2 grams 3 to 4 times daily as directed. ______ None Tetracaine 10%, Prilocaine 10%, Lidocaine 20% 100 gm 240 gm 360 gm Apply 1 to 2 grams 3 to 4 times daily as directed. ______ None Ketamine 10%, Gabapentin 5%, Amitriptyline 3%, Clonidine 0.2%, Lidocaine 20% 100 gm 240 gm 360 gm Apply 1 to 2 grams 3 to 4 times daily as directed. ______ None Diclofenac 6%, Baclofen 2%, Lidocaine 5% 100 gm 240 gm 360 gm Apply 1 to 2 grams 3 to 4 times daily as directed. ______ None Additional Directions PRESCRIBER INFORMATION SIGNATURE PRESCRIBER NAME (PLEASE PRINT) DATE OFFICE CONTACT NPI# DEA# PHONE FAX ADDRESS CITY STATE ZIP Confidentiality Notice: This fax is intended for the sole use of the individual and entity to which it is addressed, and may contain information that is proprietary, confidential, privileged and prohibited from being disclosed under applicable law. If you are not the intended addressee, nor authorized to receive for the intended addressee, you are hereby notified that you may not use, copy, disclose or distribute to anyone facsimile or any information contained in the fax. If you received this by mistake, please contact Vios at (800) 518-9831.

  2. TOPICAL PAIN PRESCRIPTION FORM 2 OF 3 Please fax completed form to (800) 537-5193 or call (800) 518-9831 31035 Schoolcraft Rd • Livonia, Michigan 48150 • vioscompounding.com PATIENT INFORMATION PLEASE FAX WITH PATIENT DEMOGRAPHIC SHEET & RX INSURANCE CARD NAME ALLERGIES DATE OF BIRTH PHONE ADDRESS CITY STATE ZIP MEDICATION / CONCENTRATION Diclofenac 4%, Lidocaine 5%, Gabapentin 5%, Pentoxifylline 3%, Clonidine 0.2%, Amitriptyline 3% SUPPLIED 100 gm 240 gm 360 gm SIG Apply 1 to 2 grams 3 to 4 times daily as directed. REFILLS ______ None NEUROPATHIC/ANTI-INFLAMMATORY 100 gm 240 gm 360 gm Apply 1 to 2 grams 3 to 4 times daily as directed. ______ None Diclofenac 3%, Lidocaine 2%, Gabapentin 5%, Amitriptyline 2%, Clonidine 0.2%, Amantadine 8% 100 gm 240 gm 360 gm Apply 1 to 2 grams 3 to 4 times daily as directed. ______ None Diclofenac 3%, Lidocaine 2%, Gabapentin 5%, Amitriptyline 2%, Clonidine 0.2%, Ketamine 10% 100 gm 240 gm 360 gm Apply 1 to 2 grams 3 to 4 times daily as directed. ______ None Ketamine 5%, Cyclobenzaprine 2%, Baclofen 2%, Lidocaine 5%, Ketoprofen 10% 100 gm 240 gm 360 gm Apply 1 to 2 grams 3 to 4 times daily as directed. ______ None Diclofenac 5%, Baclofen 2%, Bupivacaine 2%, Cyclobenzaprine 2%, Gabapentin 6%, Ibuprofen 5%, Ketamine 10% 100 gm 240 gm 360 gm Apply 1 to 2 grams 3 to 4 times daily as directed. ______ None Verapamil 15%, Diclofenac 3% FIBROMATOSIS 100 gm 240 gm 360 gm Apply 1 to 2 grams 3 to 4 times daily as directed. ______ None Verapamil 10%, Diclofenac 3%, Lidocaine 5% 4 mg/mL Dexamethasone for injection (2 x 5 ml vials) PLUS 6 Patches (select 1 below) Apply per instructions every other day for prescribed amount of time. Other _____________________ ______ None IONTOPHORETIC PATCH 4 hr STAT (80 mA-min) PATCH 14 hr 80 (80 mA-min) PATCH Ideal Location - Feet, Elbows, Knees, Wrists, Shoulders ADD Adapta-cap Syringe 1-unit Additional Directions PRESCRIBER INFORMATION SIGNATURE PRESCRIBER NAME (PLEASE PRINT) DATE OFFICE CONTACT NPI# DEA# PHONE FAX ADDRESS CITY STATE ZIP Confidentiality Notice: This fax is intended for the sole use of the individual and entity to which it is addressed, and may contain information that is proprietary, confidential, privileged and prohibited from being disclosed under applicable law. If you are not the intended addressee, nor authorized to receive for the intended addressee, you are hereby notified that you may not use, copy, disclose or distribute to anyone facsimile or any information contained in the fax. If you received this by mistake, please contact Vios at (800) 518-9831.

  3. TOPICAL PAIN MANAGEMENT PRESCRIPTION FORM 3 OF 3 Please fax completed form to (800) 537-5193 or call (800) 518-9831 31035 Schoolcraft Rd • Livonia, Michigan 48150 • vioscompounding.com PATIENT INFORMATION PLEASE FAX WITH PATIENT DEMOGRAPHIC SHEET & RX INSURANCE CARD NAME ALLERGIES DATE OF BIRTH PHONE ADDRESS CITY STATE ZIP PRESCRIBER’S CHOICE INCLUDE % STRENGTH OF 360GRAMS Diclofenac _______% Baclofen _______% Flurbiprofen _______% Cyclobenzaprine _______% Ibuprofen _______% Gabapentin _______% Ketoprofen _______% Amitriptyline _______% Meloxicam _______% Carbamazepine _______% Benzocaine _______% Imipramine _______% Bupivacaine _______% Acyclovir _______% Lidocaine _______% _______% Prilocaine _______% _______% Tetracaine _______% _______% MUST WRITE IN KETAMINE AND TRAMADOL QUANTITY: 90gm 130gm 260gm 360gm _____ gm REFILLS: PRN 1 2 3 4 5 _____ Typical SIG: Apply 1 - 2 GRAMS to affected area 4 - 6 times daily (max 12 grams daily) All Ingredients to be compounded in transdermal cream base vehicle Additional Directions SIGNATURE PRESCRIBER NAME (PLEASE PRINT) DATE OFFICE CONTACT NPI# DEA# PHONE FAX ADDRESS CITY STATE ZIP Confidentiality Notice: This fax is intended for the sole use of the individual and entity to which it is addressed, and may contain information that is proprietary, confidential, privileged and prohibited from being disclosed under applicable law. If you are not the intended addressee, nor authorized to receive for the intended addressee, you are hereby notified that you may not use, copy, disclose or distribute to anyone facsimile or any information contained in the fax. If you received this by mistake, please contact Vios at (800) 518-9831. Reset All Fields

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