o CRYO/AH o CRYO CYCLE o IVF o ICSI/AH o RECIPIENT (Egg Donation) o EGG DONOR o IUI (Partner) o IUI (Donor)
o
Cetrotide
®
0.25mg ____ Kits to be dispensed
Sig: ___________________________ ____ Refills
o Ganirelix Acetate 250mcg/0.5ml ____ PFS to be dispensed
Sig: ___________________________ ____ Refills
o Crinone
®
8% Gel Applicators ____ Apps to be dispensed
Sig: ___________________________ ____ Refills
o Endometrin
®
100mg ____ Inserts to be dispensed
Sig: ___________________________ ____ Refills
o Leuprolide Acetate 2 Week Kit ____ Kits to be dispensed
o
Extra Leuprolide Syringes to be refilled only after request by patient
Sig: ___________________________ ____ Refills
o Microdose Leuprolide Acetate Compounded Preparation
o 40mcg/0.1ml o
40mcg/0.2ml
o 50mcg/0.1ml o
50mcg/0.2ml ____ 6ml vials to be dispensed
o
Leuprolide Syringes ____ #
Sig: ___________________________ ____ Refills
o Lupron Depot
®
3.75mg ____ Kits to be dispensed
Sig: ___________________________ ____ Refills
o Progesterone in Sesame Oil 50mg/ml ____ 10ml vials to be dispensed
Sig: ___________________________ ____ Refills
o 18g 1½” 3cc syringe & needle ____ # ____ Refills
o 22g 1½” needle ____ # ____ Refills
o Progesterone Vaginal Suppositories Compounded Preparation
o 50mg o 100mg o
200mg ____ Supp. to be dispensed
Sig: ___________________________ ____ Refills
o Progesterone Vaginal Caps 200mg Compounded Preparation
____ Caps to be dispensed
Sig: ___________________________ ____ Refills
o Gonal-f
®
RFF Redi-ject
™
300IU ____ Each ____ Refills
o Gonal-f
®
RFF Redi-ject
™
450IU ____ Each ____ Refills
o Gonal-f
®
RFF Redi-ject
™
900IU ____ Each ____ Refills
Sig: ___________________________
o Prometrium
®
o 100mg o 200mg ____ Caps to be dispensed
Sig: ___________________________ ____ Refills
o Estrace
®
o 1mg o 2mg ____ Tabs to be dispensed
Sig: ___________________________ ____ Refills
o Vivelle Dot o 0.05mg o 0.1mg ____ Dots to be dispensed
Sig: ___________________________ ____ Refills
o Gonal-f
®
Multi-Dose 450IU ____ Vials to be dispensed
o
Gonal-f
®
Multi-Dose 1050IU ____ Vials to be dispensed
Sig: ___________________________ ____ Refills
o Clomiphene Citrate 50mg ____ Tabs to be dispensed
Sig: ___________________________ ____ Refills
o Follistim AQ 300IU Cartridge ____ Each ____ Refills
o Follistim AQ 600IU Cartridge ____ Each ____ Refills
o Follistim AQ 900IU Cartridge ____ Each ____ Refills
Sig: ___________________________
þ Follistim Pen ____ Pens ____ Refills
o Doxycycline 100mg ____ Caps to be dispensed
Sig: ___________________________ ____ Refills
o Medrol
®
o 4mg o 8mg o 16mg ____ Tabs to be dispensed
Sig: ___________________________ ____ Refills
o Z-pak ____ To be dispensed
Sig: ___________________________ ____ Refills
o Menopur
®
75IU Vial ____ Vials to be dispensed
Sig: ___________________________ ____ Refills
o
27g ½” needle ____ # ____ Refills
o
3cc syringe ____ # ____ Refills
o Other _______________________ ____ To be dispensed
Sig: ___________________________ ____ Refills
o Leuprolide Acetate Trigger Kit
MG to be injected: ________mg ____ Kits to be dispensed
Sig: ___Inject ml SQ for trigger shot_ ____ Refills
o Sharps Package – Sharps disposal unit, alcohol wipes, gauze,
disposal instructions, etc.
o
22g 1½” 3cc syringe and needle ____ # ____ Refills
o 18g 1½” 3cc syringe and needle ____ # ____ Refills
o 25g
5
/
8
” needle ____ # ____ Refills
o 20g 1½” filter needle ____ # ____ Refills
o Other _______________________ ____ To be dispensed
Sig: ___________________________ ____ Refills
o Other _______________________ ____ To be dispensed
Sig: ___________________________ ____ Refills
Submitted by: ___________________________________________________RN, IVF Today’s Date: _________________
Prescriber’s Signature: ______________________________________________________________ *PRESCRIBER MUST SIGN MEDICATION ORDER!
Date: _______ Dispense as written: ________________________________ Date: _______ Substitution allowed: ________________________________
FFP-Web_0117.1
PATIENT INFORMATION Anticipated Start Date: __________________
First Name: _________________________________________________ Last Name: ____________________________________________________
DOB: _______/_______/ _______ Allergies: _______________________________________ Medical Conditions: _______________________________
Address: _____________________________________________________ City: ____________________________ State: ________ ZIP: ___________
Home Phone: (________)_________-____________ Work Phone: (_______)_________-____________ Cell Phone: (_______)_________-____________
Center: __________________________________________________
Address:
__________________________________________________
__________________________________________________
Phone: _______________________ Fax: _______________________
Prescribing Physician: ___________________________________
NPI: __________________________________
DEA: __________________________________
FREEDOM FERTILITY PHARMACY
MEDICATION ORDER
Phone: 800-660-4283
Fax: 888-660-4283
