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Phone: (877) 868-4110 Fax: (877) 868-4144


FREE DELIVERY

2743 W. 15th St., Plano, TX 75075 Ph: 877-868-4110 Fax: 877-868-4144 INTRATHECAL MEDICATION LIST BACLOFEN

Strengths up to 1000mcg/ml 1001mcg/nl up to 2000mcg/ml 2001mcg/ml up to 4000mcg/ml

Up to 20cc

21 to 30cc

31 to 60cc

BUPIVACAINE

Strengths up to 8mg/ml (.8%) 8.1mg/ml up to 40mgml (4%)

Up to 20cc

21 to 30cc

31 to 60cc

CLONIDINE

Strengths up to 2000mcg/ml 2001mcg/ml to 4000mcg/ml

Up to 20cc

21 to 30cc

31 to 60cc

DROPERIDOL

Strengths up to 20mcg/ml 21mcg/ml and up

Up to 20cc

21 to 30cc

31 to 60cc

FENTANYL

Strengths up to 50mcg/ml 51mcg/ml up to 500mcg/ml 501mcg/ml up to 1000mcg/ml 1001mcg/ml up to 3000mcg/ml 3001mcg/ml up to 5000mcg/ml 5001mcg/ml up to 7500mcg/ml 7501mcg/ml up to 10,000mcg/ml 10,001mcg/ml up to 15,000mcg/ml 15,001mcg/ml up to 20,000mcg/ml 20,001mcg/ml up to 25,000mcg/ml

Up to 20cc

21 to 30cc

31 to 60cc

HYDROMORPHONE

Strengths up to 15mg/ml 15.1mg/ml up to 30.1mg/ml up to 45.1mg/ml up to 60.1mg/ml up to 80.1mg/ml up to 90.1mg/ml up to

Up to 20cc

21 to 30cc

31 to 60cc

30mg/ml 45mg/ml 60mg/ml 80mg/ml 90mg/ml 150mg/ml

KETAMINE

Strengths up to 20mcg/ml 21mcg/ml and up

Up to 20cc

21 to 30cc

31 to 60cc

MEPERIDINE

Strengths up to 50mg/ml 50.1mg/ml up to 100mg/ml 100.1mg/ml up to 200mg/ml

Up to 20cc

21 to 30cc

31 to 60cc

METHADONE

Strengths up to 25mg/ml 25.1mg/ml up to 50mg/ml 50.1mg/ml up to 80mg/ml

Up to 20cc

21 to 30cc

31 to 60cc

MORPHINE

Strengths up to 25mg/ml 25.1mg/ml up to 50mg/ml 50.1mg/ml up to 60mg/ml 60.1mg/ml up to 70mg/ml

Up to 20cc

21 to 30cc

31 to 60cc

ROPIVACAINE

Strengths up to 10mg/ml

Up to 20cc

21 to 30cc

31 to 60cc

PRIALT

CALL FOR PRICING

SUFENTANIL

Strengths up to 50mcg/ml 51mcg/ml up to 100mcg/ml

Up to 20cc

21 to 30cc

31 to 60cc

TETRACAINE

Strengths up to 10mg/ml (1%) 10.1mg/ml up to 20mg/ml (2%)

Up to 20cc

21 to 30cc

31 to 60cc

PLANO - DENTON - TYLER - SAN ANTONIO - EL PASO - MIAMI


Prescribers and  Staff

YOUR ONE-STOP SOLUTION AMERICAN SPECIALTY  PHARMACY  is  able  to  assist  you.  We  are  a  Specialty Pharmacy  with  retail  stores  with  the  ability  to  fill  ALL  of  your  patient’s  medications. Attached  you  will  find  a  Prescription  Referral  Form  for  use  with  specific  chronic illnesses.  If  your  patients  also  need  other  medications  not  listed,  just  send  the prescription  along  with  it  and  we’ll  take  care  of  that  too!

Our goal  is  to  service  all  of  the  needs  of  your  office  and  your  patients.

• A  member  of  our  team  will  fax  prescription  and  patient  status    updates  throughout  the  prescription  process •  P rior  authorizations  to  initiate  treatment •  R e-­Authorization  to  prevent  therapy  interruption •  C ost  management •  N o  cost  for  delivery  to  patient  home  or  your  office •  I njection  training  for  self  injectable  medications  at  patient    home  or  in  your  office •  D isease  and  treatment  education  prior  to  therapy  initiation •  O ngoing  side  effects  management •  C ustomize  patient  monitoring •  R efill  reminders  and  coordination •  R etail  prescriptions  to  ensure  patients  have  ONE  PHARMACY •  I nfusion  &  Compounding  services  available For  more  information  please  call  or  email: Phone:  (877)  868-­4110     |     Fax:  (888)  294-­9434     |     Email:  info@americanspecialtypharmacy.com

PLANO,TX   |     DENTON,  TX     |     SAN  ANTONIO     |     EL  PASO,  TX     |     TYLER,  TX www.AMERICANSPECIALTYPHARMACY.com


We look forward to serving you and meeting all of your pharmacy needs. OUR PRODUCTS & SERVICES

We are a full service pharmacy that specializes in: Compounded & Specialty Medications Durable Medical Equipment (DME) Nutritional Supplementation Workers’ Compensation Prescriptions Everyday Prescriptions

WE TAKE THE BURDEN OFF OF YOU

Our customer service is second to none; provided by highly trained sta . We assist each patient throughout the entire process. From contacting your insurance carrier to automatic re lls and overnight delivery.

www.AMERICANSPECIALTYPHARMACY.com


At American Specialty Pharmacy, we use the latest technology with top quality ingredients to compound safe and e ective customized medications. Our pharmacists are experts at compounding new, discontinued, back-ordered, or unavailable medications to meet speci c patient needs. We o er a full line of Professional Quality Vitamins,

Nutritional Supplements, OTC Medications, Everyday Prescriptions, Medical Equipment & Specialty Medications.

COMPLIMENTARY DELIVERY All deliveries are delivered straight to your door within 24 hours at no out-of-pocket cost to you.

AUTOMATIC REFILLS

Your re lls are lled automatically based on your prescription or physician’s approval. It is not necessary to reorder!

PLANO LOCATION

2743 West 15th Street Plano, TX 75075 P: 877-868-4110 . F: 877-868-4144

EMAIL

info@americanspecialtyrx.com

HOURS OF OPERATION Mon - Fri 9am until 7pm Sat & Sun 9am until 3pm

www.AMERICANSPECIALTYPHARMACY.com


GROWTH HORMONE

Form

American Specialty to Arrange

Ship to:

Pa ent Home

MD

e

CALL -6877 888)294-9434 EMAIL: info@americanspecialtyrx.com

Treating Patients Special PATIENT INFORMATION (Use this area or

nt demographi s)

Name: ______________________________________ Phone: __________________________ Phone 2: _________________________ Home Address: ________________________________________ City: ____________________ State: _______ Zip: _______________ DOB: ______________ SSN: _________________ Sex: Male Female Height: ____________ Weight: _____________Lbs. Allergies: ________________________________________________________________________________________________________ INSURANCE INFORMATION (Use this area or

opy of insuran

Primary Name: _____________________________________ Phone: ___________________________________________ ID#: _______________________ Group: _______________ MEDICAL ASSESSMENT (Use this area or

ard(s)

Secondary / RX: _____________________________________________ Phone: ____________________________________________________ ID#: _________________________ Group: ______________________

h pa ent labs and other authoriz

Primary Dx: ______________________ ICD9 Code: ___________ Secondary Dx: ______________________ ICD9 Code: ___________ Previous Treatment: ____________________________________ Previous Treatment Outcome:_________________________________ Is currently on Therapy? YES NO Medica s): ____________________________________________________________ PRESCRIPTION INFORMATION *(Use this area or

Genotropin

Humatrope

opy of RX(s)

Cartridge 5mg 12mg Pen 5mg 12mg Mixer Mini Quick Pre ed _______mg

Dose:

Re :

5mg vial Cartridge 6mg 12mg 24mg HumatroPen 6mg 12mg 24mg 40 mg/4mL vial

Leuprolide

5mg/mL 2.8mL mul -dose vial 14 day kit Lupron Depot 3.75mg 11.25mg Lupron Depot Ped 7.5mg 15mg 11.25mg 30mg

Nutropin AQ

Omnitrope

Saizen Tev-Tropin

Flexpro

5mg 10mg Pen 30mg

Re : Qnty: Re :

15mg

Dose:

Qnty: Re : Qnty:

Dose:

Re :

Pen Cartridge 10mg/2mL 20mg/2mL Pen for cartridge 10 20 NuSpin Pre ed 5mg 10mg 20mg 5.8mg vial Cartridge Pen 5

Qnty:

Dose:

Dose:

Increlex

Norditropin

Qnty:

Dose:

Re : Dose:

5mg/1.5mL 10

Qnty:

10mg/1.5mL

Re :

Vial 5mg 8.8mg CoolClick2 for vials 8.8mg cartridge easypod for 8.8 cartridge One click auto-injector pen 5mg Vial Tjet injector device

Qnty:

Dose:

Dose:

Qnty: Re : Qnty: Re :

Signature: ______________________________________________

Date: ___________________

Prescriber Name: _____________________________________________ NPI#: ____________________________________ Address: _________________________________ City: __________________________ State: _________ Zip: _________ Phone: ______________________________ Fax: ______________________________ Email: _______________________________________ O ce Contact: __________________________________________

FAX TO: (888) 294-9434

GHFRMVS.912


FEMALE HRT REFERRAL FORM

PRESCRIPTION

PLEASE ATTACH COPIES OF PATIENT’S INSURANCE CARDS C- PERIMENOPAUSAL:

C- PMS:

Progesterone Topical *Apply Cyclically Days 12 – 25 once a day. *Apply BID or TID week prior to period.

Progesterone Topical

C- BI–ESTROGEN TOPICAL:

*Apply Cyclically Days 1 – 25 once a day.

C- PREMENOPAUSAL:

Progesterone Topical *Apply Cyclically Days 12 – 25 once a day. *Apply BID or TID week prior to period.

QTY:

30gm (Thirty Grams)

60gm (Sixty Grams)

C- DHEA ORAL: QTY:

30gm (Thirty Grams)

C- MENO – POSTMENOPAUSAL SURGERY: Progesterone Topical

C- BI–ESTROGEN TOPICAL: *Apply Cyclically Days 1 – 25 once a day. QTY:

30gm (Thirty Grams)

60gm (Sixty Grams)

C- BI – ESTROGEN TOPICAL:

C- TESTOSTERONE TOPICAL QTY: QTY:

30gm (Thirty Grams)

30gm (Thirty Grams)

60gm (Sixty Grams)

C- TESTOSTERONE TOPICAL: QTY:

30gm (Thirty Grams)

60gm (Sixty Grams)

SEXUAL DYSFUNCTION ENHANCEMENT:

QTY:

30gm (Thirty Grams)

LIBIDO BOOST CREAM:

N.O.C. AROUSAL CREAM QTY:

30gm (Thirty Grams)

Today’s Date

QTY:

30gm (Thirty Grams)

Prescriber’s Signature

at 888-966-0188


MALE HRT REFERRAL FORM

PRESCRIPTION

Today’s Date

PLEASE ATTACH COPIES OF PATIENT’S INSURANCE CARDS

▢ ▢

Viagra

DESIGNED SUPPLEMENTS & SUPPLIES ▢

TROCHES/TABLETS ▢

CREAM, GEL & ETC - QTY: 30gm (Thrity Grams) ▢

▢ ▢

CREAM, GEL & ETC - QTY: 60ml (Sixty Milliliters) ▢

INJECTABLE - QTY: 10ml (Ten Milliliters) ▢

COMPOUNDED INTRACAVERNOSAL - QTY: 10ml (Ten Milliliters) ▢ ▢ ▢ ▢

ADDITIONAL NOTES:

Prescriber’s Signature at 888-966-0188


www.AMERICANSPECIALTYRX.com Plano | Denton | El Paso | San Antonio | Miami | Tyler | Houston

Endocrinology  

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