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Patient Name:
tneitaP
Address: City/State/Zip: Phone:
2
3844 Post Road, Warwick RI 02886 www.bayviewrx.com 401-284-4505 Phone 401-284-4506 Fax
DOB:
Topical Pain Formulations
Anti-inflammatory Creams F1 Flurbiprofen 10%, Baclofen 2%, Lidocaine 5%, Pentoxifylline 3% D1 Diclofenac 5%, Baclofen 2%, Bupivacaine 1%, Ibuprofen 3%, Pentoxifylline 3% F2 Flurbiprofen 10%, Verapamil 10%, Pentoxifylline 3%
noitpircserP
Neuropathic Creams K1 Ketamine 10%, Baclofen 2%, Gabapentin 6%, Verapamil 6%, Pentoxifylline 3% K2 Ketamine 10%, Clonidine 0.2%, Gabapentin 6%, Imipramine 3%, Lidocaine 5%, Pentoxifylline 3%
Neuropathic and Anti-inflammatory Creams D2 Diclofenac 5%, Baclofen 2%, Bupivacaine 1%, Cyclobenzaprine 2%, Gabapentin 6%, Ibuprofen 3%, Pentoxifylline 3% K3 Diclofenac 5%, Baclofen 2%, Bupivacaine 1%, Cyclobenzaprine 2%, Gabapentin 6%, Ibuprofen 3%, Pentoxifylline 3% K4 Ketamine 10%, Meloxicam 1%, Baclofen 2%, Bupivacaine 1%, Clonidine 0.2%, Cyclobenzaprine 2%, Gabapentin 6%, Pentoxifylline 3% M1 Meloxicam 0.2%, Lamotrigine 2.5%, Lidocaine 2%, Prilocaine 2% 3
Quantity/ Sig Sig: Apply 1-2gms to affected area 3-4 times daily rub in well for 1-2 minutes
ytitnauQ
Alt Sig: Qty: 240gm (30 day supply) or other quantity 180gm 120gm (1 pump = 1 gram) Refills: 0 1 2 3 4 5 6 7 8 9 10 11 12
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Signature
5
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.