COMPOUND PRESCRIPTION REQUEST FORM

Patient Name:



Contact #:




Diagnosis:


Allergies:


DOB:


~ Please attach patients demographics and Rx insurance information.~
*(Include SS# or Drivers License for Controlled Substance Compounds)
77-GA-SSathrum
Formulations and Indications

PAIN COMPOUNDS

MIGRAINE PAIN COMPOUNDS
NCP-3 Cream: Meloxicam 20%, Baclofen 2%, Cyclobenzaprine HCl
2%, Gabapentin 6%, Lidocaine HCl 2.5%
GPI-2 Cream: Topiramate 5%, Meloxicam 20%, Methocarbamol 4%
BRP-2 Cream: Dextromethorphan HBr10%, Clonidine HCl 0.2%,
Gabapentin 6%, Meloxicam 10%, Lidocaine HCl 2%
MG-1 Cream: Sumatriptan 5%, Tramadol HCl 2%,
Pentoxifylline 5%, Dexamethasone NaPO4
0.1%, Lidocaine HCl 5%

Sig: Apply 1 pump to temples and behind ears, every 2 hours, as needed for
pain. Do Not Exceed: 3 pumps per day.

AI Gel: Diclofenac Na 4%

Qty: 150 gms = 4 week supply

**AI Gel (Diclofenac Na 4%) or
NCP-1 Cream (Diclofenac Na 1%, Lidocaine 2.5 %, Prilocaine 2.5%

**MG-2 (Sumatriptan 0.5%, Baclofen 0.8%, Lidocaine HCl 2%)


*PAIN COMPOUNDS (CONTROLLED SUBSTANCE) SCAR COMPOUNDS
NCP-4 Cream: Ketamine HCl 10%, Baclofen 2%, Cyclobenzaprine
HCl 2%, Meloxicam 10%, Gabapentin 6%
STC-1 Cream: ALIPURE 17%, Diphenhydramine HCl 2%,
Prilocaine HCl 3%, Pentoxifylline 0.5%,
Hydrocortisone 2.83%
PN Cream: Ketamine HCl 4%, Diclofenac Na 4%, Amitriptlyline HCl 4%,
Gabapentin 4%, eucalyptus oil


**STC-2 (ALIPURE 1.7%, Diphenhydramine HCl 1%, Pentoxifylline 0.5%,
Hydrocortisone 1.33%)
**PN Gel (Diclofenac Na 4%, Amitriptyline HCl 4%, Gabapentin 4%, Ketamine HCl
4%, Eucalyptus Oil) OR


**AI Gel (Diclofenac Na 4%) or NCP-1 Cream (Diclofenac Na 1%, Lidocaine 2.5 %,
Prilocaine 2.5%)


WOUND CARE COMPOUNDS
*Must provide SS# or copy of Drivers License of patient.
WC-1 Cream: NADH (Nicotinamide Adenine Dinucleotide) 5%,
Nifedipine 1%, Phenytoin Na 5%, Metronidazole
Benzoate 2%



**WC-2 (NADH 0.3%, Phenytoin Na 1%, Metronidazole Benzoate 1%)







Quantity: 300 grams = 4 week supply
(may substitute 150 gms every 14 days)
SIG: Apply 1-2 pumps to affected area 3-4 times daily.
(1 pump = 1.5 grams)
Refills:
prn #





Signature:

**

Date:


Physician Name:



DEA #:




Address:



NPI #:




City/State/Zip:

Phone:




**By signing here, you, the prescriber, agree to alternatively prescribe a similar compound in the event that the originally prescribed compounded
cream is not covered by the patients insurance. If a similar compound is used, 50 gms for up to 10 days may be substituted if insurance does not
cover another size.








Rx To You Pharmacy, Inc. is a member of the International Academy of Compounding Pharmacists (IACP).

Your physician prescribed a treatment plan by combining multiple classes of medicine into a customized cream or gel. This
individualized formula is compounded in our pharmacy which specializes in topical creams and gels that treat medical
conditions directly at the source. Compounding is a long-standing pharmacy practice that allows doctors to treat their
patients individual needs without being restricted to off-the-shelf medicines.

EXPECT A CALL WITHIN 24 HOURS:
A representative from Rx To You Pharmacy, Inc. will contact you within 24 hours of receiving your prescription. Please be
alert to telephone calls coming from area codes that may not be familiar. At this time we will be verifying your address, date
of birth and prescription insurance coverage.
IF YOU HAVE NOT HEARD FROM US WITHIN THE 24 HOURS, PLEASE CONTACT US TOLL FREE AT:
(855) 879-7928 - option 5 (1-855-Try-Rx2U)

COST AND SHIPPING:
Most commercial insurance plans cover compounded topical medications. In the event that it is not covered, we will call
you. Prescriptions ship FREE to you.

INSTRUCTIONS:
Please review and follow the instructions on your medication container. Additionally, keep the following steps in mind when
applying the cream to help ensure optional relief:

1. ATTENTION SURGERY PATIENTS OR PATIENTS WITH OPEN WOUNDS Do not apply to the incision area or
any open wound, unless directed specifically by your physician.
2. Before application, wash and clean the general area with rubbing alcohol or soapy water.
3. Massage a generous amount of topical medication (1-2 FULL pump depressions) into the affected area(s) for at
least 2 minutes. Repeat every 6 hours as needed.
4. For migraine pain compounds only, apply 1 pump to temples and behind ears every 2 hours as needed for pain. Do
not exceed 3 pumps per day.
5. For optimum results, do not bathe, swim, or wash off for a minimum of 15 minutes after application. If needed,
lightly rub off after 15 minutes.
6. Do not use if pregnant or breastfeeding
7. Do not consume alcohol while using topical cream
8. STORE AT ROOM TEMPERATURE.

Side effects from topical medications are limited. Allergic reactions are rare but may result in a rash, itching, swelling, or
difficulty breathing. If you experience any of these side effects or any other side effects, stop the medication and contact
your doctor or pharmacist. If you are experiencing an emergency, please call 9-1-1.

If you have any questions about your compounded medication or how to properly apply it, please contact us.

The information on this handout is generalized and is not intended as specific medical advice.
3202 SE Federal Highway, Stuart, FL 34997
Phone: (855) 879-7928

Fax: (407) 264-6414 / (800) 971-9936