Vein Medication Experts
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Vein Medication Experts Purchase vein care medications directly from an FDA 503B Outsourcing Facility Olympia Compounding Pharmacy is a registered and inspected FDA Outsourcing Facility in Orlando, FL. Because of the extremely high standards required to operate as an FDA facility, there are only fifty FDA compounders in the United States at this time. All compounded items from Olympia Pharmacy are compounded under the new cGMP guidelines to insure the safest, highest quality compounded medications available. For more information, or to open an account please contact: Dan Powell Director of Business Development for Olympia Pharmacy Direct: 407-383-7644 Email: [email protected] Olympia Pharmacy | FDA Outsourcing Facility | 6700 Conroy Rd, Orlando FL 32835| Ph: 407-673-2222 |olympiapharmacy.com Polidocanol / STS Price List - Physicians Prescription Fax: 407-673-1234 Shipping: [ ] UPS Ground [ ] UPS 2nd Day [ ] UPS next business day Physician/Practice Name: ______________________________________________________________________ Ship to Address: ___________________________________________________ Phone: ____________________ City/State/Zip: ________________________________________________ Fax: ____________________ Physician License: ________________________________ Drug Concentration Volume Price Order Qty Polidocanol 1.25%, 1.5% 5ml $28 Polidocanol 3% 5ml $33 Polidocanol 5% 5ml $40 Polidocanol 10% 5ml $50 Glycerin 72%/ Lidocaine 1%/ with Epinephrine 1:100,000 N/A 5ml $24 Glycerin 72% Plain N/A 5ml $28 Nifedipine Ointment 0.3%/ N/A 30g $30.00 Lidocaine 1.5% Sodium Tetyradecyl Sulfate 1% 5ml $25 Sodium Tetyradecyl Sulfate 3% 5ml $27 Sodium Tetyradecyl Sulfate 5% 5ml $30 Sodium Tetyradecyl Sulfate 10% 5ml $35 Loomicaine (14% Prilocaine and N/A Any $1 / gram Lidocaine) 20%/6%/4% Benzocaine/ Lidocaine/ Tetracaine 20%/8%/6% Any $1 / gram 20%/4%/5% For Olympia Office Use Only: Shipping Fee: ________ Total with Shipping:___________ Physician Signature:________________________________ Date: _________________ rev:08-13-2015 Olympia Pharmacy | 6700 Conroy Rd, Orlando FL 32835 | Ph: 407-673-2222 | Fax: 407-673-1234 Olympia Compounding Pharmacy – An FDA Registered Outsourcing Facility Olympia Compounding Pharmacy, located in Orlando, Florida, is a state of the art FDA registered outsourcing facility. We specialize in Erectile Dysfunction, Anti-Aging, Hormone Replacement Therapy, Weight Loss, Vein Care, Dermatology and more. Why purchase medication from an FDA outsourcing facility? The Compounding Quality Act, passed in late 2013, created a new designation of compounding pharmacy, the FDA Registered Outsourcing Facility. In accordance with the new law, ONLY an Outsourcing Facility can provide medication to be administered by physicians or other medical staff. This means any and all medications administered in office, MUST come from an FDA Outsourcing Facility. Olympia can be your single pharmacy to provide both Office Use Medications, as well as Patient Specific Prescription Medications, guaranteeing quality and uniformity throughout. Why purchase from Olympia? Our staff is very knowledgeable: Olympia has knowledgeable Pharmacists and other staff, educated on our specialties, to provide unparalleled support. Olympia excels at fielding phone calls from physicians and patients alike. For clinics who obtain VIP status with Olympia, this line is available 24/7. Infrastructure: We have the infrastructure in place to receive and fill prescriptions very quickly. Prescriptions received by 5pm will ship the same day. We currently fill thousands of prescriptions each month! Beyond Use Date (BUD): Olympia performs all necessary testing to provide the longest BUD on our medications. This testing is performed by independent 3rd party, CGMP facilities and includes batch sterility, potency, endotoxin, method suitability, compatability and advanced stability testing. Without these tests, a pharmacy compounder can only provide very short BUD’s without acceptable CGMP validations. Olympia can provide much longer BUD’s, which means more convenience for your patients, who can purchase more medication to last a longer period of time. Peace of Mind: As a registered FDA Outsourcing Facility, Olympia’s medication, lab and equipment are held to a much higher standard than a traditional 797 compounder. All medication is held in quarantine for 14 days and not released until sterility and potency testing has been completed by a 3rd party laboratory. You can rest assured your patients are receiving the highest quality medication available. Olympia Compounding Pharmacy remains on the cutting edge of technology and safety, providing our patients and physicians with the safest medication, best customer service and most convenient technology. For question or to set up and account with Olympia, please contact: Dan Powell, Director of Business Development at 407-383-7644 or [email protected] Olympia Pharmacy | 6700 Conroy Dr, Ste 155 | Orlando, FL 32835 | Phone: 407-673-2222 | Fax: 407-673-1234 Credit Card / Account Setup Authorization Form Fax: (866) 249-9083 I, authorize Olympia Compounding Pharmacy to charge (print name) my credit card listed below the amount of $ . *(enter the word "BILLING" to have this card billed on a regular and ongoing basis for your account) Circle one: MC / VISA / AMEX Name on card: Card Number: CVV Code: Expiration Date: Credit Card Billing Address: address city ST Zip Shipping Address (if different from billing): address city ST Zip Cardholder Signature Today's Date Physician Name: License Number: NPI #: DEA #: **TERMS: New accounts are normally billed every 7 days. Alternate terms may be arranged by contacting Maribeth Duchano at 407-673-2222 or [email protected] 6700 Conroy Rd, Ste 155 - Orlando - FL - 32835 - Phone: 407-673-2222 6700 Conroy Rd, Ste 155, Orlando, FL 32835 Phone (407) 673 2222 Fax: (866) 249-9083 Agreement for Purchase of Compounded Office Use Medication The practitioner agrees to purchase compounded medications for Office Use from Olympia Pharmacy under the following guidelines as required per Florida rule 64B16-27.700. 1. The compounded drug may only be administered to the patient and may not be dispensed to the patient or sold to any other person or entity; 2. The practitioner shall include on the patient’s chart, medication order, or medication administration record the lot number and the beyond-use-date of any compounded drug administered to the patient that was provided by the pharmacy; 3. The practitioner will provide notification to the patient for the reporting of any adverse reaction or complaint in order to facilitate any recall of batches of compounded drugs. (Practitioner Name) (Address) (City, State, Zip) (Phone Number) Signature Date PHYSICIAN’S OFFICE CONTACT INFORMATION: Fax Completed Form to: (866) 249-9083 Date: __________ Doctor’s Name: ____________________________________________________________ Business Name: __________________________ Office Manager: ___________________ Physical Address: __________________________________________________________ ___________________________________________________________ Office phone: __________________________ Office fax: _______________________________ Other phone: ______________________ Email address (for invoices):______________________ PHYSICIAN STATEMENT REGARDING OFFICE VISIT REQUIREMENTS Dear Doctor: We understand that in some cases, the patient and the prescribing physician may reside in different states. In order to ensure that all prescriptions received by Olympia Pharmacy are pursuant to a valid doctor/patient relationship, we require that our prescribing physicians agree that the following elements are satisfied prior to sending us a prescription. For purposes of state law, many state authorities, with the endorsement of medical societies, consider the existence of the following four elements as an indication that a legitimate doctor/patient relationship has been established: A patient has a medical complaint; A medical history has been taken; A physical, in person, examination has been performed; and Some logical connection exists between the medical complaint, the medical history, the physical examination, and the drug prescribed. All controlled medication ordered as “office use” will come clearly marked as “office use” and “not for resale”. These medications are provided for the physician to administer to the patient in the office ONLY. I, , agree that all prescriptions sent to Olympia Pharmacy will meet the criteria above. I agree that there is no other agreement written, oral or otherwise that negates this one. Physician Signature__________________________________________________________________ ** Please attach copy of physician state license and DEA Permit ** .