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1
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1
Patient Information
Last Name
First Name
MI
Address
Apt. #
City
State
ZIP
Phone #
Date of Birth
Sex
Male
Female
Email
Patient will pick up at pharmacy
Please ship to patient
Please ship to office
2
Prescriber and Prescription Information
Prescriber's First Name
Prescriber's Last Name
Phone Number
Fax Number
Address
City
State
ZIP
NPI/DEA
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Tadalafil 15 mg Capsules
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Tadalafil 7.5 mg Capsules
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Phenylbutazone 10% Topical Gel (Vet)
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Zonisamide 400 mg Capsules
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Zonisamide 12.5 mg Capsules
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Zonisamide 25 mg Suppository
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Zinc Sulfate Replacement Solution (3 mg/mL of Elemental Zinc)
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Zinc Sulfate 20% Topical Gel
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Zonisamide 10 mg/ml To 100 mg/ml Oral Suspension
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Zinc Sulfate Monohydrate 0.1% Oral Solution
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Zonisamide 100 mg Suppository
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Zonisamide 25 mg/0.1 ml Topical Lipoderm® (Vet)
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Zinc Sulfate Monohydrate 137 mg Capsules
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Zinc Sulfate 10%/Manganese Chloride 0.5% Oral Solution
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Zonisamide 75 mg Capsules
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Zonisamide 150 mg Capsules
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Zinc Pyrithione 1%/Clobetasol Propionate 0.05% Shampoo
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Zinc Sulfate 3.23 mg/Gm Vaginal Gel
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Zinc Pyrithione 0.2%/Hydrocortisone 1%/Ibuprofen 2% Topical Cream
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Zinc Pyrithione 2% Topical Spray
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Zinc Pyrithione 0.2%/Cyanocobalamin 0.07% Topical Cream
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Zinc Pyrithione 0.2%/Cyanocobalamin 0.07%/Clobetasol Propionate 0.05% Topical Gel
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Zinc Pyrithione 0.2%/Tacrolimus 0.1%/Cyanocobalamin 0.07%/ Topical Cream
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Zinc Pyrithione 0.2%/Clobetasol Propionate 0.05% Topical Spray
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Zinc Sulfate 0.025% Mouth Rinse
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Zinc Pyrithione 1%/Ketoconazole 1% Shampoo
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Zinc Pyrithione 2% Topical Gel
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Zinc Pyrithione 0.2%/Clobetasol Propionate 0.05%/Cyanocobalamin 0.07% Topical Cream
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Zinc Sulfate 1%/Aluminum Sulfate 5% Topical Cream
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Zinc Pyrithione 0.2%/Cyanocobalamin 0.07%/Clobetasol Propionate 0.05% Topical Cream
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Zinc Pyrithione 0.2%/Cyanocobalamin 0.07% Topical Gel
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Zinc Gluconate 100 mg Slow Release Capsules
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Zinc Oxide 5%/Aloe Vera Oil 2%/Vitamin A Palmitate 5000 IU/ml/Vitamin E Acetate 0.1% Topical Liquid
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Zinc Oxide 10%/Hydroxyquinoline Sulfate Topical Ointment
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Zinc Oxide 3% Topical Cream
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Zinc Gluconate 1%/Chlorhexidine Gluconate 0.14% Dental Gel (Vet)
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Zinc Oxide 5%/Mupirocin 2%/Nystatin 100,000 Units/Gm Topical Gel
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Zinc Oxide 12.5%/Lidocaine 5%/Pramoxine HCl 1% Topical/Rectal Gel
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Zinc Pyrithione 0.2%/Clobetasol Propionate 0.05% Topical Cream
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Zinc Pyrithione 0.2%/Clobetasol Propionate 0.05% Topical Gel
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Zinc Oxide 5%/Camphor 1%/Phenol 1.87%/Boric Acid 2% Rectal Ointment
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Zinc Oxide 10%/Aluminum Hydroxide 2.5% Topical Ointment
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Zinc Oxide 20%/Cholestyramine 5% Topical Ointment
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Zinc Oxide 10%/Hydrocortisone 1%/Lidocaine 1% Topical/Rectal Gel
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Zinc Pyrithione 0.2% Shampoo
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Zinc Oxide 8%/Cholestyramine 4%/Miconazole 2%/Mupirocin 2% Topical Gel
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Zinc Gluconate 0.5%/Amino Acid Topical Lotion (Vet)
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Zinc Pyrithione 0.2% Topical Spray
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Zinc Gluconate 0.5% Nasal Spray
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Zinc 10 mg/ml Oral Suspension
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Xylometazoline HCl 0.05% Nasal Solution
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Zidovudine 20 mg/ml Oral Suspension
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Zinc Acetate 1% Topical Solution
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Zinc Chloride 1% Topical Solution
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Xylometazoline HCl 0.1% Nasal Solution
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Xylitol 66.7% Oral Gel
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Xylitol 66.7% Oral Syrup
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Zinc Acetate 0.5%/Boric Acid 1% Topical Solution
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Xylitol 60% Oral Syrup
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Vitamin E 200 U/Gm Vaginal Gel
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Xylitol 3% Mouthwash
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Voriconazole 1% Ophthalmic Solution (Pf)
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Vitamin E Acetate 100 U/ml/Coenzyme Q-10 15 mg/ml/Beta Carotene 1249 IU/ml Oral Suspension
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Warfarin Sodium 5 mg Capsules (Gluten Free)
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Warfarin Sodium 10 mg Capsules (Gluten Free)
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Xylitol 7% Oral Rinse
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Warfarin Sodium 7.5 mg Capsules (Gluten Free)
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Xylitol 40% Oral Syrup
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Warfarin Sodium 1 mg/ml Oral Suspension
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Vitamin E Acetate 200 U/ml Vaginal Cream
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Warfarin Sodium 2.5 mg Capsules (Gluten Free)
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Vitamin E 400 IU Vaginal Suppository
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Verapamil HCl 60 mg Slow Release Capsules
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Verapamil HCl 10%/Magnesium Chloride Hexahydrate 10% Topical Gel
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Verapamil HCl 100 mg Slow Release Capsules (Gluten Free)
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Radio 3
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Verapamil HCl 10%/Diclofenac Sodium 5% Topical Gel
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Radio 3
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Vitamin E 100 IU Vaginal Suppository
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Radio 3
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Verapamil HCl 50 mg/ml Oral Suspension
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Verapamil HCl 240 mg Slow Release Capsules (Gluten Free)
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Radio 3
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Verapamil HCl 15% Topical Gel
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Radio 3
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Vitamin A/D/E Suppository
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Radio 3
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Vitamin E 200 IU Vaginal Suppository
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Radio 3
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Verapamil HCl 180 mg Slow Release Capsules (Gluten Free)
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Radio 3
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Verapamil HCl 40 mg/ml Topical Gel
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Verapamil HCl 120 mg Slow Release Capsules (Gluten Free)
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Verapamil HCl 10%/Pentoxifylline 5% Topical Gel
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Vancomycin 200 mg/Amphotericin B 5 mg/Betamethasone 0.5 mg Capsules (For Nasal Irrigation/Nebulizer)
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Vancomycin 250 mg/Gm/Mupirocin 2% Otic Gel
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Vancomycin 160 mg Capsules (For Nasal Irrigation/Nebulizer)
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Vancomycin 200 mg/Tobramycin 100 mg/Betamethasone 0.5 mg Capsules (For Nasal Irrigation/Nebulizer)
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Vancomycin 500 mg/60 ml/Metronidazole 250 mg/60 ml Rectal Suspension Enema
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Vancomycin 50 mg/ml Oral Suspension
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Vancomycin 160 mg/Mometasone Furoate 0.6 mg Capsules (For Nasal Irrigation/Nebulizer)
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Vancomycin 50 mg/Mupirocin 20 mg Capsules (For Nasal Irrigation/Nebulizer)
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Vancomycin 200 mg/Tobramycin 125 mg/Betamethasone 0.5 mg Capsules (For Nasal Irrigation/Nebulizer)
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Verapamil HCl 10%/Diclofenac Sodium 5%/Baclofen 2% Topical Gel
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Vancomycin 250 mg/Gm Otic Gel
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Vancomycin 200 mg/Betamethasone 0.5 mg Capsules (For Nasal Irrigation/Nebulizer)
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Verapamil HCl 10% Topical Gel
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Vancomycin 250 mg Capsules (Gluten Free)
Next
Directions:
QTY:
Refills
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2
3
4
5
6
7
8
9
10
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Prescriber's Signature:
Date
3
Fill out the Pharmacy Name and Fax Number, then fax it to the Pharmacy.
Pharmacy Name
Pharmacy Fax Number
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