FEMALE BHRT AND OB GYN PRESCRIPTION FORM
1 OF 4
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
MEDICATION / TYPE
STRENGTH
QUANTITY
SIG
REFILLS
0.5mg 0.625 1mg 1.25mg
2mg 5mg 10mg ___ mg
30 days 60 days ______
apply ___ gm qD 1 PO qD
______ PRN None
Tri-Est cream capsule troche 80/10/10 ___ /___ /___
0.5mg 0.625 1mg 1.25mg
2mg 5mg 10mg ___ mg
30 days 60 days ______
apply ___ gm qD 1 PO qD
______ PRN None
Progesterone cream capsule
25mg 50mg 75mg
100mg 200mg ___ mg
30 days 60 days ______
apply ___ gm qD 1 PO qD
______ PRN None
________________________________ (must write Testosterone) cream capsule troche
1mg 2mg 4mg
5mg 10mg ___ mg
30 days 60 days ______
apply ___ gm qD 1 PO qD
______ PRN None
DHEA cream
5mg 10mg 15mg
20mg ___ mg
30 days 60 days _____
apply ___ gm qD 1 PO qD
______ PRN None
25mg 50mg 100mg
250mg ___ mg
30 days 60 days ______
___ PO qD
______ PRN None
0.5mg 0.625 1mg 1.25mg
2mg 5mg 10mg ___ mg
30 days 60 days ______
Bi-Est cream 80/20
BHRT
STATE ZIP
capsule 70/30
capsule
troche 50/50
___ /___
troche
troche
Pregnenolone capsule Estriol (E3) Estradiol (E2) cream capsule troche
Estrone (E1) vaginal cream
apply ___ gm qD 1 PO qD PV 1gm qHS 14 days, PV gm qHS 2 times week for 14 days, PRN
______ PRN None
CUSTOM: 30 days 60 days ______
Yes No
Combination (1) cream / capsule
apply ___ gm qD 1 PO qD
______ PRN None
Additional Directions
PRESCRIBER INFORMATION
PRESCRIBER NAME (PLEASE PRINT)
NPI#
ADDRESS
SIGNATURE
DEA#
DATE PHONE
CITY
OFFICE CONTACT FAX
STATE
ZIP
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