Office Name: ______Patient Name: ______Address: ______Address: ______City: ______State: ______Zip: ______City: ______State: _____ Zip: ______DOB: ____ /____ /_____ Phone: ( ) ______- ______Allergies: ______Phone: ( ) ______- ______** All prescriptions are intended for prescribed patient **

MALE PERFORMANCE & TRT Medication (must write Testosterone) Concentration Supplied Directions Refills Cypionate 200mg/ml with 10ml  ______Cypionate PLUS INJ ____ml ____ weekly

(sesame oil) Enanthate 20mg/ml □ include INJ kit  none Cypionate 180mg/ml 10ml  ______Bi-blend INJ ____ml ____ weekly (sesame oil) Propionate 20mg/ml □ include INJ kit  none  cream  50mg 100mg  30gm  60gm  ____ Apply _____ gm QD ______ transdermal gel  200mg  90gm  none  5ml  2 x 5ml INJ 0.5ml SQ  2  3 QWK  ____ Gonadorelin Acetate (in solution) 200mcg/ml □ include INJ kit (inj kit: 31 gage – 1ml syringe)  none Clomiphene Citrate / Anastrozole  30mg / 0.125mg Months  1 PO QD  ____ (capsule)  60mg / 0.5mg  1  2  3  1 PO 3 QW  PRN DHEA  10mg  15mg  apply ___ gm qD  ____  30  60  90  cream  capsule  troche  20mg  ___ mg  1 PO qD  PRN

Pregnenolone  50mg  100mg  apply ___ gm qD  ____

Testosterone Replacement Therapy Replacement Testosterone  30  60  90  cream  capsule  troche  250mg  ___ mg  1 PO qD  PRN  ____ Combination (1) cream  YES  NO  30  60  90  apply ___ gm qD  PRN

Medication (must write controlled) Concentration Supplied Directions Refills 12ml □ ______ ____ Sermorelin 1000mcg/ml

□ include INJ kit □ INJ 0.3ml SQ QD Mon – Fri  PRN 10ml  ______Deconate 200mg/ml INJ ___ml ___ weekly □ include INJ kit  none

, Oxandrolone  12mg  28mg  Troches  ____ Deconate Nandrolone Nandrolone ______ RC64-Cachexia

& &  57mg  Dye-free Capsule (12mg, 25mg)  none  Troche: completely dissolve  ¼  ½  1 troche under tongue QD  ____ GHRH Directions for Oxandrolone  Capsule: take 1 capsule by mouth QD  none

2mL INJ 0.1 - 0.2 SQ prior to sexual  ____ Bremelanotide (sq injection) 10,000mcg/ml □ include INJ kit activity, maximum 3 WK or 8 MO  PRN Bremelanotide with Methylcobalamin  10  20 1 PO under tongue 30 minutes  ____ PT141 2000iu / 1mg (sublingual troche)  30 prior to sexual activity  PRN Tadalafil / Bremelanotide / Oxytocin  10  20  ½  1 PO under tongue 30  ____ 25mg / 2000iu / 125iu  (sublingual troche)  30 minutes prior to sexual activity  PRN Medication Concentration Supplied Quantity Refills Sildenafil with Apomorphine 2mg  25mg  50mg  Troches  90  60  1  2  ___

 oxytocin 125 units  100mg  Dye-free Capsule  30  10  PRN  none

Vardenafil with Apomorphine 2mg  5mg  10mg  Troches  90  60  1  2  ___  oxytocin 125 units  20mg  Dye-free Capsule  30  10  PRN  none Avanafil with Apomorphine 2mg  50mg  100mg  Troches  90  60  1  2  ___  oxytocin 125 units  200mg  Dye-free Capsule  30  10  PRN  none  Troche: completely dissolve  ¼  ½  1 troche under tongue 30 minutes prior to sexual activity Directions

 Capsule: take 1 capsule by mouth 30 minutes prior to sexual activity PDE5 inhibitors PDE5 Sexual Support / Support Sexual Tadalafil with Apomorphine 2mg  5mg  10mg  Troches  90  60  1  2  ___  oxytocin 125 units  20mg  Dye-free Capsule  30  10  PRN  none  Troche: completely dissolve  ¼  ½  1 troche under tongue  once daily  1-2 hours prior to sexual activity Directions  Capsule: take 1 capsule by mouth  once daily  1-2 hours prior to sexual activity Additional SIG:

Prescriber Name: ______

Prescriber Signature: ______

DEA #: ______NPI #: ______Date: ___ /___ /_____

Supervising Physician: ______DEA #: ______RPS2021