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Patient Information

Patient Name:

tneitaP

Address: City/State/Zip: Phone:

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

DOB:

Urology/Erectile Dysfunction Most Commonly Prescribed

     Other Varieties

Sildenafil Tablets

Tadalafil Buccal Troches (Lozenge)            Tadalafil 5mg Troche

         Sildenafil 20mg Tablets

noitpircserP

Sildenafil Rapid Dissolve Tablets

         Tadalafil 10mg Troche

         Sildenafil 25mg RDT

         Tadalafil 15mg Troche

         Sildenafil 50mg RDT

         Tadalafil 20mg Troche

         Sildenafil 75mg RDT

Sildenafil Buccal Troches (Lozenge)

         Sildenafil 100mg RDT

           Sildenafil 25mg Troche

Tadalafil Rapid Dissolve Tablets

           Sildenafil 50mg Troche

        Tadalafil 5mg RDT

           Sildenafil 75mg Troche

        Tadalafil 10mg RDT

           Sildenafil 100mg Troche

        Tadalafil 15mg RDT           Tadalafil 20mg RDT

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Quantity/ Sig Sig (Tablet): Place 1 tablet on tongue and allow to dissolve.

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Sig (Troche): Place 1 troche between cheek and gum and let dissolve (~20-30min) Alt Sig: Qty: 30  or other quantity          60       90       Other Refills:     0       1       2       3       4       5       6       7       8       9       10       11       12 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.

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