TriMix is made up of 3 different medicines and must be ...

[Pages:3]Although a prescription is necessary to obtain TriMix, following the procedures on this page will simplify the process.

"TriMix is made up of 3 different medicines and must be prescribed by a licensed physician. "

1. Present the TriMix prescription fax order form to your physician (usually your family doctor or urologist).

2. Physician completes and faxes form to Olympia Pharmacy. 3. (Optional) Include the completed credit card authorization form

for faster processing. Olympia's staff WILL call patient to verify amount before any charge is made. If credit form is NOT included with fax, Olympia's staff will contact patient directly by phone within 24 hours of receiving prescription to get payment information. TriMix will not ship until full payment has been made. 4. Olympia ships TriMix directly to you, the patient. Medication must be shipped for delivery on next business day, as it must be shipped on ice in a cooler. For this reason, TriMix will NOT normally be shipped on a Friday.

Once prescription form is received by Olympia Pharmacy please allow up to 24 hours (excluding weekends) to be contacted by our staff.

If your physician has any questions about TriMix formula's, dosing or procedures please have then contact Dan Powell at dan@ or call 407-383-7644

6700 Conroy Road, ste 140 -Orlando, FL 32835 - 407-673-2222 -

Credit Card Authorization Form Fax: 407-673-1234

I, _________________________ authorize Olympia Compounding Pharmacy to charge

(print name)

my credit card listed below, the amount of $_______________.

Circle one: MC / VISA / AMEX

Name on card:__________________________________________________________

Card Number:__________________________________________________________

CVV Code:_________________

Expiration Date: _____________

Credit Card Billing Address: _______________________________________________

address

city

ST Zip

Shipping Address (if different from billing):

______________________________________________________________________

address

city

ST

Zip

____________________________________________________________________________________

Cardholder Signature

Today's Date

6700 Conroy Road, ste 140 -Orlando, FL 32835 - 407-673-2222 -

TriMix

Prescription Fax Order: 407-673-1234

Patient Information Ship to: [ ] Patient Address [ ] Office Address

**TriMix must be kept cool and will be shipped to arrive next business day.

Name: ___________________________________________________________________________Date: _________________

Address: __________________________________________City:_______________________ST:_________Zip:___________

Phone: _________________________________Email: ____________________________________ D.O.B. _______________

[ ]TriMix Standard (Papaverine 30mg / Phentolamine 1mg / Alprostadil 10 mcg/ml)

[ ]TriMix Plus

(Papaverine 30mg / Phentolamine 1mg / Alprostadil 25 mcg/ml)

[ ]Quad Mix (Papaverine 30mg / Phentolamine 1mg / Alprostadil 25mcg / Atropine .2 mg/ml)

[ ]Super Quad (Papaverine 30mg / Phentolamine 1mg / Alprostadil 50mcg / Atropine .2 mg/ml)

[ ]Custom ( _____Papaverine mg/ml / _____ Phentolamine mg/ml / _____Alprostadil mcg/ml _____Atropine mg/ml)

[ ]Phenylephrine 1mg/ml 5ml (inject .5ml in case of priapism, repeat every 15 mins. up to 6 injections)

** Circle Quantity: 5ml 10ml _____ ml [ ]Other: 30 Syringes 1cc / 30g / 1/2" and 30 Alcohol Swabs

Sig:____________________________________________________________________________________

For Physician If you would like to receive information about Olympia's compounded medications including ED, Anti Aging, Weight Loss, Vein Care, Bio Identical Hormones, men's health, women's health or performance nutraceuticals, please fill out the contact info below.

Name:_________________ Phone:__________________ Email:_______________________ Fax:___________

Address/ City/ State / Zip:______________________________________________________________________

Comments:__________________________________________________________________________________

Print Physician Name: ___________________________________________ Date:______________ Physician Phone:___________________________________________________________________ Physician Signature: _____________________________________________ Refills:_____________ Physician License:________________

6700 Conroy Road, ste 140 -Orlando, FL 32835 - 407-673-2222 -

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