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.