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Patient Name:

tneitaP

Address: City/State/Zip: Phone:

3844 Post Road, Warwick RI 02886 www.bayviewrx.com 401-284-4505 Phone 401-284-4506 Fax

DOB:

         Patient will pick up at pharmacy          Please ship to patient

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Anal Pain Formulations

Hemorrhoids H1         Hydrocortisone 2% / Lidocaine 3% Rectal Rocket Suppository H2         Hydrocortisone 2% / Lidocaine 1% Topical Ointment Anal Fissure / Thrombosed External Hemorrhoids

noitpircserP

D12       Ditiazem 2% Topical Gel N5         Nifedipine 0.2% Rectal Ointment N6         Nitroglycerin 0.125% Topical Ointment N7         Nitroglycerin 0.2% Topical Ointment N9         Nitroglycerin 0.3% Topical Ointment N10       Nitroglycerin / Lidocaine 0.4-2% Topical Ointment Other Compound

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Quantity/ Sig

ytitnauQ

Sig (Ointment): Apply 2-3 times per day. Sig (Rectal Rocket): Insert one suppository QHS x 5 nights. Alt Sig: Qty (ointment): 30 gms Qty (Rectal Rocket): 5 ea Refills:     0       1       2       3       4       5       6       7       8       9       10       11       12       NR 4

Signature

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naicisyhP

Prescriber Signature

Prescriber Name

Address: Phone:

Date

City/State/Zip: Fax:

DEA#

For professional use only. Bayview Pharmacy specializes in customizing medications to meet unique patient and prescriber needs. Above are examples of some commonly prescribed formulations across a diverse array of specialties, and is not meant to encourage the use of any formula contained within. Please apply your professional judgement within the scope of your specialty when prescribing. Bayview Pharmacy dispenses only to individually identified patients with valid prescriptions. No compounded medication is reviewed by the FDA for safety or efficacy. Bayview Pharmacy does not compound copies of commercially available products.

Anal pain formulations%2f rectal rocket order form website  
Anal pain formulations%2f rectal rocket order form website  
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