PATIENT INFORMATION - Olympia Pharmacy

Clinic/ Physician name: Address: City:

Name: Address: Phone:

Account #

PRESCRIPTION ORDER

*Email tracking to:

Account Open Date

MUST CHECK ONE Fax: 407-673-1234 Bill Physician Bill Patient

This is a refill

Phone:

ST: Email

Zip: PATIENT INFORMATION

City:

State:

MUST CHECK ONE

Ground

2nd Day

Overnight

DOB: Zip:

MUST CHECK ONE:

503B Label

PGE1 PGE2 PGE3 BM3 T-50 NB-143 NB-243 NB-343 T-101 T-105 T-106 SB4 SB5 SB6 ST2 RE1 RE2 FormF1 QM1 QM2 QM3 QM4 FormF9

FA

Patient will pick-up at pharmacy

Papaverine mg/ml

Phent. mg/ml

30

3

8

0.29

30

3

30

3

30

3

17.65

0.59

30

1

30

1

30

3

30

3

30

3

30

3

30

3

30

3

1.8

0.2

30

3

30

3

30

3

30

3

0.9

0.1

20

2

Ship to patient address

PGE mcg/ml 40 80 150

Atropine mg/ml

2.9

10

20

30

5.9

10

25

40

50

60

100

200

300

18

.02

10

0.2

60

0.2

150

0.2

300

0.2

20

.01

20

0.2

Ship to office address

"Reversal Medication" in case of priapism Include Phenylephrine 1mg/ml 5ml

Dispense Qty: 2.5ml

5ml

Sig:

10ml

# of syringes / bags of 10 2 / 1cc | 30 gauge | 1/2"| alcohol swabs

Autoject II

Physician Name (Print): NPI:

Phone:

Refills:

Physician Signature:

Date:

Olympia Pharmacy | 6700 Conroy Road Ste. 155 | Orlando, FL 32835 | | 407-673-2222

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