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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:

Topical Pain Formulations

Anti-inflammatory Creams

Neuropathic Pain

D3        Diclofenac 4% Topical F2         Flurbiprofen 10%, Verapamil 10%, Pentoxifylline 3% I20        Ibuprofen 20% Topical

D2        Diclofenac 5%, Baclofen 2%, Bupivacaine 1%,               Cyclobenzaprin 2%, Gabapentin 6%, Ibuprofen 3%,               Pentoxifylline 3%  D4        Diclofenac 5%/Gabapentin 5%/Amitriptyline HCL 2%

K6         Ketoprofen 10% Topical

noitpircserP

F4        Flurbiprofen 10%, Cyclobenzaprine HCL 1%,               Gabapentin 6%, Lidocaine 2%, Prilocaine 2%

P5        Piroxicam 5% Topical

Anti-inflammatory/Muscle Relaxant Combinations D1        Diclofenac 5%, Baclofen 2%, Bupivacaine 1%, Ibuprofen 3%,               Pentoxifylline 3% F3         Flurbiprofen 10%, Baclofen 2%, Cyclobenzaprine HCL 2%,               Tetracaine 2% Topical F1          Flurbiprofen 10%, Baclofen 2%, Lidocaine 5%,               Pentoxifylline 3%

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% K3        Ketamine 10%, Diclofenac 5%, Baclofen 2%,              Cyclobenzaprine 2%, Bupivacaine 1%, Gabapentin 6%,              Ibuprofen 3%, Pentoxifylline 3% K4        Ketamine 10%, Meloxicam 1%, Baclofen 2%,              Cyclobenzaprine 2%, Clonidine 0.2%, Bupivacaine 1%,              Gabapentin 6%, Pentoxifylline 3%

K7        Ketoprofen 10%, Cyclobenzaprine HCL 2% Topical

K5       Ketamine HCL 5%, Gabapentin 10%, Clonidine HCL 0.2%,              Baclofen 2%

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M1      Meloxicam 0.2%, Lamotrigine 2.5%, Lidocaine 2%,             Prilocaine 2%

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

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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.

Topical pain formulations order form v 3 website  
Topical pain formulations order form v 3 website  
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