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    Doctor's Name*
    Doctor's Address
    Person Submitting Info's Name & Role*
    Ex: Nancy, RN

    Patient Info

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    Medication Info

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

    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.