MULTIPLE SCLEROSIS -
PROKARIN ORDER FORM

TO:  The Compounder Pharmacy
340 Marshall, Unit 100 * Aurora, IL 60506
630-859-0333     FAX: 630-859-0114

Patient Information

Name:                                                                       Date:

Address:

City, State, ZIP:

Date of Birth:                         Telephone:                            email:

Suggested Order for Prokarin^®

Strength:  Histamine Phosphate 0.2, Caffeine Citrate 100

Quantity:  1 month supply with patches

Refills:  _____________________

SIG:  Apply with patch and ramp slowly as directed on enclosed instructions.

Prescriber Information

Name (print)                                                  (MD, DO, other_______)

Signature:

Address:

City, State, ZIP:

Phone:                                  FAX:                                 email:

License No.:                                  DEA: