Rx  Name:________________

          Date:_________________

          Pt. Phone:_____________

Compounded Medication (please indicate it's a compounded prescription)

Generic name of active ingredient(s)/ Strength or Dose (i.e. % or mg)

____________________________________________________

Dosage Form (i.c., Transdermal, suppository, capsule, troche)

_______________________________________________

Quantity ___________________

Sig ______________________________________________

_________________________________________________

Doctor name (print): ____________________

Doctor phone: ______________________

Doctor: _________________________