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Name: ___________________________________ D.O.B. ______________ Phone #: _____________________
Address: ______________________________________________________________________________________
Date: _________________
Sterile Compound RX (please check one)
____ Autologous Serum Eye Drops (ASED)
(please circle strength) 20% 25% 40% Other: _________
Sig: Instill 1 drop into each eye 4 to 6 times each day
Other Sig: ______________________________________
Quantity: As many 2ml bottles as serum will make, up to a 90 day supply. (Each bottle lasts approx. 3 days)
Refill _____________ times
Lab Orders
____Collection of venous blood by venipuncture
CPT Code 36415
ICD Code 370.33 Dry Eyes
____ Albumin Eye Drops
(please circle strength) 5% 10% 20% 25% (max strength)
Sig: Instill 1 drop into each eye 4 to 6 times each day
Other Sig: ______________________________________
Quantity: Dispense a 45 day supply in multiple bottles. (Each bottle lasts approx. 3 days)
Refill _____________ times
Dr. _______________________________________________________ DEA#______________________
Please Print Name _______________________________________ Phone #: ______________________
Address ______________________________________________________________________________
Faxed by: _______________________________________________
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