rx - The Compounder

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Doctor's Name(Required)

First Last

Email(Required)

Upload Signed Prescriptions Here(Required)

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Doctor's Signature(Required)

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Doctor's Name*

First Last

Doctor's Phone #*

Doctor's Fax #*

Doctor's Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Doctor's DEA or NPI #*

Person Submitting Info's Name & Role*

Name Role

Ex: Nancy, RN

Email Address*

Patient Info

Patient Name*

First Last

Species

Other

Patient Date of Birth*

Patient Phone #*

Patient Email

Patient Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Medication Info

Medication Name*

Medication Strength*

Medication Form*

Medication Instructions*

Days Supply*

As per FDA's GFI 256, it is required to note the medical rationale for prescribing a compounded medication over a commercially available medication*

Patient is allergic to a specific ingredient in the FDA approved product

Specific ingredient in FDA approved product is toxic to this species

Patient would require too many pills/tablets of FDA approved product

Patient needs a dose that would require a fraction of an approved tablet and tablet is not scored to accomplish this fractionated dose

Patient cannot safely be pilled with the FDA approved capsule

Commercial product is not available, in short supply, or on backorder

Commercial product is not available in requested dosage form

Other

If #1 is checked, please list ingredient here

If #2 is checked, please list ingredient here

If other is checked, please list here

Refills Given*

Doctor's Signature*

This document will be immediately sent to you electronically through email in order to receive the proper signature from the prescribing doctor. Please return to this form and upload it, or FAX to 630-859-0114, or attach to an email and send to thecompounderpharmacy@gmail.com.

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Text Us 630-381-7413!

rx

Please fill out the form below
OR
upload the RX here

Patient Info

Medication Info

OUR LOCATION

Text Us 630-381-7413!

Text Us 630-381-7413!

rx

Please fill out the form below OR upload the RX here

Patient Info

Medication Info

Please fill out the form below
OR
upload the RX here