Hormone Replacement Prescription Fax Form - Healthway Coumpounding Pharmacy

Saginaw Pharmacy
Fax Number: 989 791-4603

Healthway Compounding
Pharmacy
Bio-Identical Hormone Replacement
http://www.healthwayrx.com

St. Charles Pharmacy
Fax Number: 989 865-6216

Patient Name:____________________________________ Date:_____________
Address:____________________________________ Phone:________________
City, State, Zip:______________________________________________________
D.O.B.:___________________ Drug Allergies:_____________________________

Hormone:	Estrogen	and/or	Progesterone	and/or	Testosterone
	Tri-est Bi-est Estriol		Progesterone		Testosterone Methyltestosterone
Dosage Form:	Capsule Transdermal (Recommended form) Other:________		Capsule Transdermal Other:________		Capsule Transdermal Other:________
*Strength:	Estrogen		Progesterone		Testosterone
	0.2mg 0.5mg 0.75mg 1.0mg Other:_______ ____________ QTY:_______ RF:_________		10mg (Transdermal) 25mg (Transdermal) 125mg (P.O.) 175mg (P.O.) 225mg (P.O.) Other:______ ___________ QTY:_______ RF:________		0.25mg 0.5mg 0.75mg 1mg Other:_______ ____________ QTY:________ RF:_________
Directions:	____________________ ____________________ ____________________ ____________________ ____________________		___________________ ___________________ ___________________ ___________________ ___________________		______________ ______________ ______________ ______________ ______________
Check here if you would like these combined into the same dosage unit (capsule, troche, etc.)
Doctor:_______________________________________________ *These are merely guidelines. The dose can be compounded to the specific needs of the individual.