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MNEMONIC General Compound Form.Docx

MNEMONIC General Compound Form.Docx

Meta Pharmacy Services 8352 West Warm Springs Rd, suite 120 Las Vegas, NV 89113 Tel: 702-754-0172, Fax: 702-754-6996 www.metapharmacyservices.com Patient Full Name: ______DOB: _____/ _____/ ______Allergies: ______Address: ______Cell Phone #:(______) ______Diagnosis/ ICD-9/ 10: ______Work Comp/ PIP: Y___N___Claim #______Please Fax Patient Demographics: Insurance, Medications,and

INFLAMMATORY Pain CREAM FORM ULATI ON UN LESS SPECFI ED MP1 -☐ 2%, Cyclobenzaprine 2%, Diclofenac 3%, Tetracaine 2% NEUROPATHIC Pain MP2 -☐(General) – 6%, Baclofen 2%, Cyclobenzaprine 2%, Diclofenac 3%, Tet racaine 2% MP3 -☐ (Moderate) – Clonidine 0.2%, Gabapentin 6%, 3%, Dextromethorphan 8%, 3%, Tetracaine 2% MP4 -☐ (Severe) – Amityriptyline 4%, Baclofen 2%, 2%, Clonidine 0.2%, Dextromethorphan 8%, Gabapentin 8%, 2%

Pai n OTHER Pain MP5 -☐ (Myofacial/ TMJ) – Baclofen 2%, Cyclobenzaprine 2%, Diclofenac 3%, Gabapentin 6%, 5%, Tetracaine 2% MP6 -☐ (Gout) – Diclofenac 5%, Indomethacin 5%, 5%, Cream MP7 -☐ (Post Herpetic Neuralgia) - Acyclovir 4%, 2%, Bupivacaine 1%, 2-Deoxy-D-Glu 2%, Flurbiprofen 5%, Gabapentin 6% MP8 -☐() -Arginine 0.4%, Bethanechol 0.1%, Hydrocortisone 1%, Lidocaine 5%, Nifedipine 0.2%, Pramoxine 2% (PAIN sig: Apply 1-4 Pumps to Affected Areas 3-4 times Daily)

Healing Promotion Document MW1 -☐Sterile Wound Cr 1 – Bupivacaine 5%, Fluticasone 0.1%, Hyaluronic Acid 1%, Loperamide 5%, Metronidazole 2%, Misoprost 0.003%, 5% Anti-Infective + Healing Promotion MW2 -☐Sterile Wound Cr 2–Gentamicin 0.2%, Vancomycin 5%, Bupivacaine 5%, Hyaluronic Acid 1%, Loperamide 5%, Misoprost 0.003%, Phenytoin 5% Wound MW3 -☐Sterile Wound Cr 3 – Itraconazole 5%, Bupivacaine 5%, Hyaluronic Acid 1%, Loperamide 5%, Misoprostol 0.0024%, Mupirocin 5%, Phenytoin 5% (sig: Apply 2-4 Pumps to Affected Areas 2-4 times Daily with each Dressing Change) MD1 -☐Dermatitis 'Gel'- CoQ10 4%, Methylcobalamin 0.07%, Mometasone 0.2%, Bupivacaine 2%, Hydroxyz 2% (sig: Apply 1-4 pumps t o AA 2-3 x qDay) MD2 -☐Eczema –Bet amet hasone 0.05%, 3%, Levocet rizine 2%, Tranilast 2% (sig: Apply 1-4 pumps t o AA 2-3 x qDay) MF5 -☐Acne Gel –Clindamycin 2%, Erythromycin 2%, Metronidazole 0.75%, Salicylic Acid 2% (sig: Apply 1-4 pumps t o AA 2-3 x qDay) MD3 -☐Psor i asi s* –CoQ10 4%, Methylcobalamin 0.07%, Mometasone 0.2%, Vitamin E 0.05%, Tretinoin 0.02% (sig: Apply 1-4 pumps t o AA 2-3 x qDay) MD4 -☐Athlete’s Foot –Fluconazole 2%, Tea Tree Oil 5%, Terbinafine 2%, Urea 40% (sig: Apply 1-4 pumps t o AA 2-3 x qDay) MM4 -☐Female Libido * –Theophylline 2.4%, ARG 10%, Niacinamide 5%, NifedipineServices 2%, Papaverine 5%, Pentoxifylline 5% (sig: Apply 1-4 pumps t o AA 2-3 x qDay) MM6 -☐Male ED Gel* –Alprostadil0.05%, Papaverine 0.06%, Phentolamine 0.02% (sig: Apply to Clitoris 30 Min Prior to Sexual Activity) (sig: Apply 1 pump to Penis 20 Min Before Sex) MH2 - ☐Hair Loss Soln**–Liothy 0.00025%, Melaton 1%, Minox 5%, Pregnen 0.5%, Palmet 0.05%, Proges 0.025%, Spiron 0.05% Dermat ology (sig: Apply 5mL t o AA/ Scalp qDay) MD5 - ☐Burn –Aloe Vera 0.2%, Ketoprofen 2%, Lidocaine 2%, Misoprostol 0.0024%, Phenytoin 5% (sig: Apply 1-4 pumps t o AA 2-3 x Daily) MD6 - ☐Nail Fungus Solution* * –Ciclopirox 8%, Ibuprofen 2%, Terbinafine 1%, Urea 20% *30GM Default Dispense Size **60mL Default Dispense Size (sig: Apply 6 drops t o AA 2-4 x Daily)

MN1 -☐Migraine/ Tension Headache – (C-IV, Hard Copy Rx)Doxepin 5%, Gabapentin 5%, Indomethacin 5%, Sumatriptan 5%, Tramadol 5% MN2 -☐Refractory Headache (C-II, must bring hardcopy to pharmacy) - Flurbiprofen 6%, Hydrocodone 1%, Ondansetron 0.4% Neuro (sig: Apply 1-3 Pumps to Back of Neck at Hairline or AA 2-3 x Daily PRN)

MN3 -☐Nausea – Ondansetron 1%, 2.5%

N/ V (sig: Apply 1 Pump to Inner Wrist, then Rub Wrist Together, and Apply 1 Pump to Back of Neck at Hairline q4hr PRN N/V) MS6 -☐Warm Up – Camphor 8%, Dimethyl Sulfone 10%, Emu Oil 10%, Eucalyptus Oil 3%, Menthol 8% (sig: Apply 1-4 Pumps to AA Prior to Activity)

s MS7 -☐Recovery GelPharmacy – Baclofen 2%, Cyclobenzaprine 2%, Gabapentin 6%, Ketoprofen 20%, Lidocaine 2% (sig: Apply 1-4 Pumps to AA Post Exercise)

Sp o r t MS8 -☐Excessive Per spir at ion Gel – Aluminum Chloride 20%, Salicylic Acid 4% (sig: Apply 1-2 Pumpsto AA PRN)

MH3 - ☐Testosterone Gel - Testosterone 10% MH5 - ☐Estriol Cream – Estriol 0.1%

HRT HRT MH4 - ☐Test Cream – Testosterone 6% MH6 - ☐ Biestrogen Cream – Estriol 0.08%, Estradiol 0.02% (sig: Apply 1-2 Pumps to Upper Arms and Shoulders qDay) (sig: Apply 1-4 Pumps to AA 1-2 x qDay as Directed) MS1 - ☐Sca r A w a y – Diclofenac 1%, Hydrocortisone 3%, Pentoxifylline 3%, Salicylic Acid 2%, Tranilast 1%, 8% MetaMS2 - ☐Scar Fade/ Stretch Mark – Hyaluronic Acid 1%, Hydrocortisone 3%, Pentoxifylline 3%, Tranilast 1%, Verapamil 8%, Vit amin E 2%

Scar META SCAR PROTOCOL -☐ MS1 (Scar Away) x (2-4 weeks), + MS2 (Scar Fade/ Stretch Mark) X (2-4 weeks) (sig: Apply 1-3 Pumps to Affected Areas 2-3 times qDay as Directed)

☐Custom Compound- ______

Alternate sig: ______(1 Pump=0.5 GM) Disp: ☐ 30GM ☐ 60GM ☐ 120GM ☐ 360GM ☐ Alt Qty______Prescriber: ______DEA#: ______Refills: ______Phone: ______

Signature: ______Date: ______FAX TO: 702-754-6996 META PHARMACY SERVICES

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