<p> American Hormones, Inc. - Order Form Patient Name: ______Refill: 1 2 3 4 5 1yr Date: ______Address: ______Phone: ______Date of Birth: ______TRI-EST SR Capsules (Estriol, Estradial, Estrone) Dose: 0.5mg 1.0mg 1.5mg 2.0mg other: _____ Progesterone SR Capsules Quantity: ______Dose: 50mg 100mg 125mg other: _____ Sig: Take ______cap/s orally in the AM Quantity: ______Refill: 1 2 3 4 5 1yr Sig: Take ______cap/s orally in the PM Refill: 1 2 3 4 5 1yr TRI-EST Cream (Estriol, Estradial, Estrone) Dose: 1.25mg/ml 1.75mg/ml 2.0mg/ml 2.5mg/ml other: ____mg/ml Progesterone Cream Quantity: ______ml Dose: 25mg/ml 50mg/ml 100mg/ml other: ____mg/ml Sig: Apply ______ml to intact skin ___ time/s daily Quantity: ______ml Refill: 1 2 3 4 5 1yr Sig: Apply ______ml to intact skin ____ times daily Refill: 1 2 3 4 5 1yr BI-EST SR Capsules (Estradiol /Estriol,) Dose: 1.0mg/0.5mg 1.5mg/0.5mg 2.0mg/0.5mg other: ____mg/0.5mg Progesterone Triturate (12 per blister pack) Quantity: ______Dose: 25mg 50mg 100mg other: _____ Sig: Take ______cap/s orally in the AM Quantity: ______Refill: 1 2 3 4 5 1yr Sig: Dissolve ______under the tongue____ times daily Refill: 1 2 3 4 5 1yr Estriol Facial Cream 30gm Dose: 0.3% 0.5% Testosterone Gel (alcohol base) Quantity: ______Dose: 50mg/ml 70mg/ml 90mg/ml other: ____mg/ml Sig: Apply ______time/s daily Quantity: ______ml Refill: 1 2 3 4 5 1yr Sig: Apply ______ml to intact skin ___ time/s daily Refill: 1 2 3 4 5 1yr Compounded Thyroid T3/T4 SR Dose: 15mg 30mg 60mg 90mg 120mg other: _____mg Testosterone Vanishing Cream (water soluble base) Quantity: ______Dose: 10mg/ml 20mg/ml other: ____mg/ml Sig: Take ______cap/s orally in the AM Quantity: ______ml Refill: 1 2 3 4 5 1yr Sig: Apply ______ml to intact skin ___ time/s daily Refill: 1 2 3 4 5 1yr DHEA Dose: 25mg 50mg 100mg other: _____mg Melatonin SR Quantity: ______Dose: 1mg 2mg 3mg other: _____mg Refill: 1 2 3 4 5 1yr Quantity: ______Co Q10 Refill: 1 2 3 4 5 1yr Dose: 30mg 60mg other: _____mg Quantity: ______Fax signed script to 866-597-7601 Prescribing Physician: ______DEA # ______Signature Please PRINT Physician’s Name & Address: ______Phone: ______</p><p>______</p>