Outpatient Pharmacy Employee OTC Order Form Phone:(518) 324 ...

[Pages:6]Outpatient Pharmacy Employee OTC Order Form

Phone:(518) 324-3784

Fax:(518) 562-7187

Name: ___________________ Phone:(___)_________ Employee#:____________

OFFSITE DELIVERY LOCATION NEEDED FOR ALL DELIVERIES:________________________

Pharmacy is not responsible for offsite transport of OTC items and recommends 48 hours notice

Item

Acetaminophen Infants Acetaminophen 325 mg Acetaminophen 500 mg Acetaminophen 650 mg [Tylenol 8 hour] Acetaminophen PM 500 mg [Tylenol PM] Acetaminophen Children's Grape Acetaminophen Children's Cherry Acetaminophen Ages 2 ? 6 Acetaminophen Ages 6 ? 11 Acid Gone Antacid Acid Gone Antacid [Gaviscon] Advanced Antacid [Maalox] Airborne Citrus Airborne Citrus Airborne Very Berry Airborne Very Berry Antacid Tablets 500mg [Tums] Fruit Antacid Tablets 500mg [Tums] Mint Antacid Tablets 750mg [Tums] Aspirin 81 mg Aspirin EC 81 mg Aspirin 325 mg Aspirin EC 325 mg Bisacodyl 5 mg [Dulcolax] Bismatrol [Pepto-Bismol] Bismatrol Cetirizine 10 mg [Zyrtec] Cetirizine 1mg/mL Chlorpheniramine 4 mg [Chlortrimeton] Coricidin HBP Day and Night Coricidin HBP Chest Congestion & Cough Chloraseptic Sore Throat Lozenges Cherry Chloraseptic Spray [Phenaseptic]

Package Size

2 fl oz 100 tablets 100 gelcaps 100 caplets 50 caplets 4 fl oz 4 fl oz 30 rapid tablets 24 rapid tablets 100 chewable tablets 12 fl oz 12 fl oz 32 chewable tablets 10 effervescent tabs 32 chewable tablets 10 effervescent tabs 150 chewable tablets 150 chewable tablets 96 chewable tablets 36 chewable tablets 100 tablets 100 tablets 100 tablets 100 softgels 8 fl oz 30 chewable tablets 100 tablets 4 fl oz 100 tablets 24 softgels 20 softgels 18 lozenges 6 fl oz

Regular Price 5.00 2.99 6.73 8.25 5.17 5.15 5.15 2.37 2.00 3.59 4.17 3.33 7.27 7.26 7.27 7.26 3.44 3.63 3.44 2.50 1.86 1.38 1.90 2.35 3.63 2.19 8.20 6.20 1.78 7.40 6.36 3.55 2.84

Employee Price 4.25 2.54 5.72 7.01 4.40 4.38 4.38 2.02 1.70 3.05 3.55 2.83 6.18 6.17 6.18 6.18 2.92 3.09 2.92 2.12 1.58 1.17 1.61 2.00 3.09 1.86 6.97 5.27 1.51 6.29 5.41 3.02 2.41

Quantity

**Prices and products subject to change without notice**

Item

Package Size

Cough DM [Delsym] Day Time Cold & Flu (DayQuil) Day Time Cold & Flu [DayQuil] Day Time Cold & Flu [DayQuil] DayQuil Cold & Flu DayQuil Cold & Flu DayQuil Cold & Flu Delsym 12 hour [Orange or Grape] Dimaphen Cold & Allergy [Dimetapp] Dimaphen DM Cough & Cold [Dimetapp] Dimetapp Cold & Allergy Dimetapp DM Cough & Cold Diphenhydramine 12.5mg/5mL [Benadryl] Diphenhydramine 25 mg [Benadryl] Diphenhydramine 25 mg [Benadryl] Docusate Sodium 100mg Docusate 50mg & Senna 8.6mg [SenokotS] Excedrin Tension Headache (Acet/Caff) Famotidine 10 mg [Pepcid AC] Fexofenadine 180 mg [Allegra] Fexofenadine 180 mg [Allegra] FiberLax Flonase Flonase Flonase Folic Acid 800 mcg Gas Relief (Simethicone 80 mg) Gas Relief Drops Infants [Mylicon] Halls Breezers Cool Berry Halls Breezers Tropical Chill Halls Breezers Creamy Strawberry Halls Defense Strawberry Halls Defense Creamy Lemon [Sugar Free] Halls Plus Cherry Halls Plus Honey Lemon Halls Strawberry Halls Spearmint Halls Ice Peppermint Halls Mentho-Lyptus Halls Honey Halls Tropical Fruit

3 fl oz 8 fl oz 12 fl oz 24 softgels 8 fl oz 12 fl oz 16 liquicaps 3 fl oz 4 fl oz 4 fl oz 4 fl oz 4 fl oz 4 fl oz 100 capsules 100 minitabs 100 softgels 100 tablets 100 caplets 30 tablets 30 tablets 100 tablets 90 caplets 60 sprays 120 sprays 2 x 120 sprays 250 tablets 100 chewable tablets 1 fl oz 25 drops 25 drops 25 drops 30 drops 17 drops 25 drops 25 drops 30 drops 30 drops 30 drops 30 drops 30 drops 30 drops

Regular Price 6.99 7.39 8.79 6.09 8.48 10.34 8.35 11.32 5.89 5.89 6.54 6.54 3.92 5.88 6.28 4.99 5.99 13.19 6.66 17.07 41.63 8.83 17.49 26.25 50.19 7.22 3.52 2.37 2.35 2.35 2.35 2.35 2.35 2.35 2.35 2.35 2.35 2.35 2.35 2.35 2.35

Employee Price 5.94 6.28 7.47 3.86 7.21 8.79 7.10 9.62 5.01 5.01 5.56 5.56 3.33 5.00 5.34 4.24 5.09 11.21 5.66 14.51 35.38 7.50 14.87 22.31 42.66 6.14 2.99 2.01 2.00 2.00 2.00 2.00 2.00 2.00 2.00 2.00 2.00 2.00 2.00 2.00 2.00

Quantity

**Prices and products subject to change without notice**

Item

Package Size

Halls Black Cherry [Sugar Free] Halls Assorted Mint [Sugar Free] Halls Citrus Blend [Sugar Free] Halls Mountain Menthol [Sugar Free] Halls Honey Berry [Sugar Free] Headache Relief (Acet/Asa/Caff)[Excedrin] Ibuprofen Infants (Dye Free) Ibuprofen 200 mg Ibuprofen 200 mg Ibuprofen 200 mg Ibuprofen 100mg/5mL Bubblegum Ibuprofen 100mg/5mL Grape Ibuprofen Jr 100 mg Ages 2 ? 11 Grape Loratadine 10 mg [Claritin] Loratadine 5mg/5mL Loperamide [Immodium AD] Luden's Wild Berry Luden's Honey Lemon Luden's Honey Licorice Luden's Wild Cherry Miconazole 7 [Monistat 7] Motrin Infants (Dye Free) Mucinex 12 hour 600 mg Mucinex DM 12 hour Mucinex Cold, Flu & Sore Throat Children's Mucinex Naproxen 220 mg [Aleve] Nasacort Nasacort Nasal Decongestant PE Nasal Decongestant Spray [Afrin] Nexium Nexium Nite Time Cold & Flu [NyQuil] Original Nite Time Cold & Flu [NyQuil] Original Nite Time Cold & Flu [NyQuil] Cherry Nite Time Cold & Flu [NyQuil] NyQuil Cold & Flu Original NyQuil Cold & Flu Omeprazole 20 mg [Prilosec] Omeprazole 20 mg [Prilosec]

25 drops 25 drops 25 drops 25 drops 25 drops 100 tablets 1 fl oz 100 tablets 500 tablets 80 softgels 4 fl oz 4 fl oz 24 chewable tablets 100 tablets 4 fl oz 18 caplets 30 drops 30 drops 30 drops 20 drops 45 grams 1 fl oz 20 tablets 20 tablets 20 caplets 4 fl oz 100 tablets 60 sprays 120 sprays 18 tablets 30 mL 28 capsules 42 capsules 8 fl oz 12 fl oz 8 fl oz 16 softgels 12 fl oz 16 softgels 14 tablets 28 tablets

Regular Price 2.11 2.11 2.11 2.11 2.11 6.59 8.87 5.50 13.99 6.95 5.59 5.59 4.13 8.82 8.11 3.45 1.68 1.68 1.68 1.59 7.99 10.11 13.25 15.35 15.17 9.29 6.89 16.99 23.59 2.55 4.50 22.99 29.99 6.25 8.79 6.25 4.69 9.95 10.35 10.36 18.49

Employee Price 1.79 1.79 1.79 1.79 1.79 5.60 7.54 4.68 11.89 5.91 4.75 4.75 3.51 7.50 6.89 2.93 1.43 1.43 1.43 1.35 6.79 8.59 11.26 13.05 12.89 7.90 5.86 14.44 20.05 2.17 3.83 19.54 25.49 5.31 7.47 5.31 3.99 8.46 7.66 8.81 15.72

Quantity

**Prices and products subject to change without notice**

Item

Omeprazole 20 mg [Prilosec] Plan B Polyethylene Glycol 3350 [Miralax] Polyethylene Glycol 3350 [Miralax] Pregnancy Test Prevacid 15 mg Prevacid 15 mg Tussin Mucus & Chest Congestion Tussin CF Multi-Symptom Cold Tussin DM Cough & Chest Congestion Tussin DM [Sugar Free] Tylenol Infants Ranitidine 75 mg [Zantac] Ranitidine 150 mg [Zantac] Ricola Honey Herb Ricola Cherry Honey Robitussin Cough Robitussin Cough & Cold Robitussin Cough & Chest Congestion Urinary Pain Relief Zegerid OTC

Package Size

42 tablets 1 tablet 14 doses 30 doses 1 test 28 capsules 42 capsules 8 fl oz 8 fl oz 8 fl oz 8 fl oz 1 fl oz 60 tablets 24 tablets 24 drops 24 drops 4 fl oz 4 fl oz 4 fl oz 30 tablets 14 capsules

Regular Price 23.17 46.70 11.99 14.99 6.99 22.49 30.49 5.05 6.75 6.55 10.25 6.40 9.72 8.79 2.39 2.39 6.59 7.25 7.25 5.67 13.11

Employee Price 20.90 39.70 10.19 12.74 5.94 19.12 25.92 4.29 5.74 5.57 8.71 5.44 8.26 7.47 2.03 2.03 5.60 6.16 6.16 4.82 11.14

Quantity

**Prices and products subject to change without notice**

Outpatient Pharmacy Employee OTC Order Form Phone:(518)324-3784 Fax:(518)562-7187

Name: ___________________ Phone:(___)_________ Employee#:____________

OFFSITE DELIVERY LOCATION NEEDED FOR ALL DELIVERIES:________________________

Pharmacy is not responsible for offsite transport of OTC items and recommends 48 hours notice

Item

Abreva Cold Sore Treatment Abreva Cold Sore Treatment Alcohol Prep Pads Ammens Medicated Powder Anbesol Oral Pain Relief Regular Strength Cool Mint Antifungal Cream (Miconazole Nitrate 2%) Aquaphor Baby Advanced Therapy Healing Ointment Arthritis Cream Odor Free (Aspercreme) Aspercreme Odor Free Aveeno Baby Eczema Therapy Moisturizing Cream Aveeno Baby Soothing Relief Moisturizing Cream Aveeno Intense Moisture Skin Relief Hand Cream Bacitracin Ointment Benadryl Itch Stopping Cream Bengay Cold Therapy Biofreeze Gel Blistex Medicated Lip Balm Blistex Mediated Lip Ointment Calamine Lotion Caldyphen Lotion (Caladryl) Calmoseptine Ointment Jar Calmoseptine Ointment Tube Cetaphil Moisturizing Cream Cetaphil Moisturizing Cream Cetaphil Gentle Skin Cleanser Pump Bottle Cetaphil Eczema Calming Body Wash ChapStick Classic Cherry ChapStick Original Chest Rub (Vick's Vapo Rub) Clotrimazole Cream 1% (Lotrimin AF) Desitin Maximum Strength Diaper Rash Paste Dibucaine Ointment 1%

Package Size

2g tube 2g pump 200 pads 11 oz (311 g) 0.33 oz (9 g) 1.5 oz (42.5 g) 3 oz (85 g) 3 oz (85 g) 3 oz (85 g) 5 oz (141 g) 5 oz (141 g) 3.5 oz (100 g) 1 oz (28 g) 1 oz (28.3 g) 4 oz (113 g) 8 fl oz 1 stick 0.35 oz (10 g) 6 fl oz 6 fl oz 2.5 oz (71 g) 4 oz (113 g) 3 oz (85 g) 16 oz (453 g) 8 fl oz 10 fl oz 1 stick 1 stick 1.76 oz (50 g) 1 oz (28.35 g) 2 oz (57 g) 1 oz (28 g)

Regular Price 20.19 21.39 3.49 6.03 7.19 5.90 9.59 4.09 6.99 8.25 6.05 8.25 5.29 5.25 8.99 22.98 1.89 2.69 6.09 3.89 6.09 6.79 8.89 16.32 9.25 17.29 1.99 1.99 3.95 7.19 5.75 6.82

Employee Price 17.16 18.18 2.97 5.13 6.11 5.02 8.15 3.48 5.94 7.01 5.14 7.01 4.50 4.46 7.64 19.53 1.61 2.29 5.18 3.31 5.18 5.77 7.56 13.87 7.86 14.70 1.69 1.69 3.36 6.11 4.89 5.80

Quantity

**Prices and products subject to change without notice**

Item

Hemorrhoidal Pads with Witch Hazel (Tucks) Herpecin L Lip Balm Stick SPF 30 Hibiclens Hibiclens Hydrocortisone Cream 1% Hydrocortisone Ointment 1% Hydrogen Peroxide Icy Hot Medicated Patch Arm, Neck & Leg Icy Hot Pain Relieving Gel Kleenex KT Tape Hero Pink KT Tape Rage Red KT Tape Sonic Blue KT Tape Winter Green Lidocare Patch [4% Lidocaine] Nasal Aspirator Bulb Nasal Aspirator Bulb and Ear Syringe Nice'n Clean Makeup Remover Wipes Nix Lice Killing Creme Rinse 2 pack and Nit Combs Orabase Maximum Strength Oral Pain Reliever Orajel Baby Gel Preparation H Suppositories Preparation H Ointment Purell Hand Sanitizer Simply Saline Wound Wash Terbinafine Cream 1% (Lamisil AT) Terbinafine Cream 1% (Lamisil AT) ThermaCare Heatwraps Lower Back & Hip S-M ThermaCare Heatwraps Lower Back & Hip L-XL ThermaCare Heatwraps Neck, Wrist & Shoulder ThermaCare Heatwraps Menstrual Pain Therapy ThermaCare Heatwraps Knee & Elbow Thermometer 20 Second Flexible Tip Thermometer Probe Covers Tiger Balm Large Patch (8 x 4 inches each) Tiger Balm Patch (4 x 2.75 inches each) Triple Antibiotic Ointment Vaseline Advanced Healing Lip Therapy Vicks BabyRub Soothing Ointment Vicks VapoRub

Package Size

100 pads 1 stick 4 fl oz 32 fl oz 1 oz (28 g) 1 oz (28.35 g) 8 fl oz 5 patches 2.5 oz (70.8 g) 85 tissues 20 precut strips 20 precut strips 20 precut strips 20 precut strips 3 patches 1 bulb 1 each 25 towelettes 2 fl oz each 0.42 oz (11.9 g) 0.33 oz 12 suppositories 2 oz (57 g) 8 fl oz 7.1 fl oz 0.5 oz (15 g) 1 oz (30 g) 2 heatwraps 2 heatwraps 3 heatwraps 3 heatwraps 2 heatwraps 1 thermometer 30 probe covers 4 patches 5 patches 1 oz (28 g) 0.35 oz (10 g) 1.76 oz (50 g) 1.76 oz (50 g)

Regular Price 5.48 5.19 6.29 16.04 3.25 1.56 1.49 6.59 5.39 2.00 20.49 20.49 20.49 20.49 15.95 2.29 4.50 5.49 20.79 5.89 5.05 9.23 14.29 3.19 6.37 7.99 14.59 7.29 8.29 8.39 7.29 7.29 6.59 1.35 7.39 6.19 6.09 1.29 4.79 4.29

Employee Price 4.66 4.41 5.35 13.63 2.76 1.33 1.27 5.60 4.58 1.70 17.42 17.42 17.42 17.42 13.56 1.95 3.82 4.67 17.67 5.01 4.29 7.84 12.15 2.71 5.41 6.79 12.40 6.20 7.05 7.13 6.20 6.20 5.60 1.15 6.28 5.26 5.18 1.10 4.07 3.65

Quantity

**Prices and products subject to change without notice**

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