MULTIPLE SCLEROSIS -
ORDER LIVER INJECTION

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

Patient Information

Patient Name:                                                                                    Date:

Address:

City, State, ZIP:

Date of Birth:                                           Telephone:

Suggested Order for Liver & Thiamin Injections  (Ref: Dale Humpherys)

(1) THIAMINE INJECTION 200 mg thiamine/ml, 30 ml quantity=_____
SIG:  Inject 1 ml IM daily as directed
(2) LIVER EXTRACT INJECTION 10 ml      quantity=_____
(Nutrients in Liver)
SIG: Inject 2 ml IM weekly (0.5ml 4 times per week on Mon Wed Fri Sun)
(3) Syringes and Needles   quantity=_____
SIG: For use with thiamine and liver injections

Refills:_____________________

Prescriber Information

Name (print)                                                             (MD, DO, other_______)

Signature

Address

City, State, ZIP

Phone                                                                  FAX

License Number                                                   DEA Number

When appropriate, the pharmacist will contact the doctor by telephone.