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Prescribe Topical Dutasteride, Minoxidil, Salicylic Acid (The Compounder)
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Date
MM slash DD slash YYYY
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Patient's Email
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Prescriber Email
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Provider Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
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Patient Allergies
*
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Gender
*
Select Gender
Male
Female
Undisclosed
Prescription (Pharmacy)
*
MINOXIDIL : SAL ACID : DUTASTERIDE :: PROPANEDIOL : ANHYD ALC *HD*
Dose
*
6% : 2% : 0.1% (Formula# 10089)
7% : 2% : 0.25% (Formula# 10090)
Other
Other Dose
Size
*
60 mL
Other
Other Size
Refills
*
0 Refills
1 Refills
Quantity
*
Choose an option
1
2
3
Days Supply
Send to Email/Fax
*
The Compounder (email)
The Compounder (fax)
vinay (email)
vinay (fax)
Other
Other Send To Email/Fax
If fax enter: 1xxxxxxxxx@send.mfax.io
Instructions
*
1
2
3
Other
Other Instructions
Adjuct prescription/supplies
*
Pharmacist Note
*
If patient calls for refill, please go ahead and refill, but notify Vinay at 815-351-2801.
Statement of Clinical Necessity
*
The compounded medications listed are made at the request of the prescribing practitioner due to the medical need of a specific patient and the preparation is prescribed because the prescriber has determined that the preparation will produce a clinically significant therapeutic response compared to a commercially available product.
Patient Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Signature
Comments
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