Phone 1.877.811.MEDS (6337) Fax 800.910.7195 SmartPharmacy.com

Your prescription has been faxed to

SMART PHARMACY

Fax: (800) 910-7195 Phone: (877) 811-MEDS (6337)

** SHIPPING IS ALWAYS FREE

Your physician has prescribed a topical cream to treat your pain and inflammation. Please review the following information about your prescription.

HOW DO I FILL MY PRESCRIPTION? HOW DO I APPLY THE CREAM? • In most cases, your physician’s office will fax your The proper application of the cream is imperative to achieve prescription directly to Smart Pharmacy. A Smart Pharmacy maximum results; therefore, be sure to follow directions on the Registered Pharmacy Technician will begin processing your prescription label. prescription and contact you by phone. • Your prescription will arrive in an easy-to-use pump applicator. • Please leave a good contact number for calling or texting in order to expedite your order. • Clean and dry the affected area prior to applying topical cream with each application. • With your approval, the prescription will be shipped directly to your home or business at no charge. • Use latex gloves or thoroughly wash hands before and after each application. Do not apply to open wounds. Do not touch eyes or WILL INSURANCE COVER MY SMART mouth before washing hands as you may cause burning and irritation. PHARMACY PRESCRIPTION? • Most commercial insurance plans cover topical preparations with a reasonable co-pay. • Apply a liberal amount to affected area and rub in well as directed by your physician, massaging the affected area for 1-2 minutes. • Smart Pharmacy will verify your coverage and discuss your co-pay obligation. This obligation can be paid over the phone via credit card or submitted with the invoice included when • The cream will absorb into skin within 30 minutes of application. you receive your prescription. Excess cream remaining on skin after that time can be gently wiped away.

• If your insurance does not cover compounded formulations, • Avoid heat, heating pads and sunlight to area treated. you can choose to purchase the medication or an alternative

at an affordable price. A Smart Pharmacy representative will • Do not wash or bathe the affected area for 1 hour after application discuss all available options.

• Cream may feel cool and tingly when applied, which is normal.

WHO IS SMART PHARMACY? Smart Pharmacy is a modernized compounding and retail CAN I FILL MY OTHER PRESCRIPTIONS AT pharmacy that specializes in transdermal creams to treat pain SMART PHARMACY? and inflammation. We also make natural hormones and vitamin YES. Smart Pharmacy has a full line of retail prescriptions and can supplements specific to a patient’s nutritional needs. ship them directly to your door. Smart Pharmacy has a successful history working with patients Please contact Smart Pharmacy anytime at 1-877-811-MEDS (6337) and physicians to address specific needs that can’t be met with for immediate service or visit us online at SmartPharmacy.com and current manufactured products. select “Transfer Prescription”.

WHAT IF I HAVE ADDITIONAL QUESTIONS? Call our dedicated customer service staff at 904-361-3861. Our Phone: 1.877.811.MEDS (6337) pharmacists are available from 9am–6pm Monday through Friday Fax: 800.910.7175 for patient consults to ensure you achieve maximum results when applying the cream. ** SHIPPING IS ALWAYS FREE

This patient information sheet was prepared and provided by Smart Pharmacy as an educational service to the community. If you receive instructions from your physician that differ from the information on this patient information sheet, you should always follow your physician’s instructions.

SP0103 rev07/14 Phone 1.877.811.MEDS (6337) Fax 800.910.7195 SmartPharmacy.com

Pain Therapy PLEASE ATTACH PATIENT DEMOGRAPHIC Patient Name: ______Date: ______Last MI First Address: ______DOB: ______Allergies: ______SS# ______Patient Phone# ______Cell Phone# ______Insurance Company: ______Member ID# ______All pumps deliver 1.5 grams of active cream. Up to 4.5 grams may be used per application. T RANSDERMAL PAIN FORMULAS Sig: Apply to affected area 3-4 times daily. Allow 30 min to absorb

■ PAIN-NC RELIEF CREAM* ■ MUSCULOSKELETAL CREAM Additions: Amantadine 8% anesthetic Lidocaine 5% anesthetic ■ Menthol 2.5% ■ Cetyl Myristoleate 2% Gabapentin 10% neuropathic Ketoprofen 5% anti-inflammatory Baclofen 2% anti-spastic Loperamide 5% analgesic ■ Diclofenac 5% ■ DMSO Clonidine 0.2% analgesic Gabapentin 5% neuropathic ■ Lidocaine 5% Magnesium 2% muscle relaxer Cyclobenzaprine 2% muscle relaxer Duloxetine 1% neuropathic Clonidine 0.2% analgesic

■ NEURO-NC CREAM* Duloxetine 1% neuropathic Amantadine 8% anesthetic ORTHO CREAM Gabapentin 6% neuropathic ■ *for formulas requiring a controlled substance, please contact pharmacy Flurbiprofen 15% anti-inflammatory Ketoprofen 5% anti-inflammatory Lidocaine 5% anesthetic Lidocaine 1% anesthetic DMSO 10% penetrating agent Clonidine 0.2% analgesic Loperamide 5% analgesic Loperamide 5% analgesic Triamcinolone 0.1% anti-inflammatory steroid Magnesium 2% muscle relaxer Duloxetine 1% neuropathic Apply 1/2 pump to back of neck at onset of headache. Reapply in 2 hours if no relief. ■ OCCIPITAL PAIN CREAM Max 1 pump (1.5 grams) daily. Do not use if you have coronary heart disease or uncontrolled blood pressure. Sumatriptan 9% Bupivacaine 1% Lidocaine 5% Clonidine 0.2% Cyclobenzaprine 2% serotonergic anesthetic anesthetic analgesic muscle relaxer Caffeine 5% Ondansetron 1% Flurbiprofen 5% Magnesium Chloride 1% analgesic adjuvant antiemetic muscle relaxer All pumps deliver 1.5 grams of active gel. Up to 3 grams may be used per application. T RANSDERMAL WOUND FORMULAS Apply 1-2 pumps directly to wound and/or dressing 3-4 times daily. ■ WOUND CARE GEL Phenytoin 5% tissue regeneration antibiotic ■ Omit antibiotics ■ Omit antifungal Misoprostol 0.0024% tissue softening/dilation Metronidazole 2% antibiotic Do not prescribe Wound Care Gel to patients with wounds covering Aloe Vera 1% Moisturizer Vancomycin 5% antibiotic more than 20% of body or who are pregnant and/or breastfeeding. Use Prilocaine 2% anesthetic Itraconazole 1% antifungal caution in women of childbearing age. All pumps deliver 1.5 grams of active gel. Up to 1.5 grams may be used per application. T RANSDERMAL SCAR FORMULA Apply 1-2 pumps directly to scar 2 times daily. SCAR GEL ■ Gabapentin 15% Prilocaine 3% Pentoxifylline 0.5% Fluticasone Propionate 1% Levocetirizine Dihydrochloride 2% neuropathic anesthetic steroid antihistamine

WELLNESS INFORMATION ■ B12 (25mg Methylcobalamin) plus Folic Acid (5mg Methyltetrahydrofolate) as a Sublingual Tablet Sig: Dissolve one tablet under the tongue every morning. PRESCRIPTION INFORMATION ound formulas three hundred sixty grams) (Scar formula one hundred eighty grams) per thirty day supply will be shipped by default if no Qty chosen. For Smaller areas ______g

Physician Name: ______DEA# ______

Address: ______Date: ______

Physician Signature: ______

us by phone to arrange the return of the original documents. I have reviewed by patient’s medical record(s) and determined that the items that I have ordered are medically necessary. I verify that I have had a face to face examination with the above patient. I agree to comply with state and federal documentation requirements by retaining a copy of this prescription in the patient’s medical record(s). The prescription is to be dispensed as written unless otherwise instructed by me. These compounded products have not been tested or approved by the FDA for their intended use.

SP0103 rev07/14 Phone 1.877.811.MEDS (6337) Fax 800.910.7195 SmartPharmacy.com

Common Formulas Containing Controlled Substances - Reference

Pain Relief Cream

-Ketamine 5% anesthetic -Gabapentin 10% neuropathic

-Baclofen 2% anti-spastic -Clonidine 0.2% analgesic

NEURO-Cream

-Ketamine 15% anesthetic -Gabapentin 6% neuropathic

-Ketoprofen 5% anti-inflammatory -Lidocaine 1% anesthetic

-Clonidine 0.2% analgesic

Additions:

Tramadol 5%

Methadone 5%

Morphine 5% plus Diphenhydramine and Triamcinolone

Morphine 10% plus Diphenhydramine and Triamcinolone

Narcotic compounds, 30 day supply with no refills (requires blue fraud proof Rx mailed to pharmacy)

Phone: (800) 910-7195 Fax: (877) 811-MEDS (6337)

SPPR rev07/14