Fillable Fax ImprimisRx 855-405-4669

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Fax ImprimisRx 855-405-4669

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Fax
To:
Comments:
Fax:
PROTECTED HEALTH INFORMATION
BUSINESS CONFIDENTIAL INFORMATION
855-405-4669
From:
ImprimisRx
Fax:
Phone:
Date:Number of Pages:
This fax is intended only for the exclusive use of the addressee(s), and may contain privileged or confidential
information. If you are not the intended recepient, or the person responsible for delivering the fax to the intended
recepient, be advised you have received this fax in error and that use, dissemination, distribution, or copying of this
communication is strictly prohibited. If you have received this fax in error, please destroy the attached document(s)
and immediately notify the sender of the error.
Please deliver to: with this cover sheet to protect its contents.
Tel: Home
Patient:
Age:
Work:
Address:
City:
M F
Cell:
DOB:
ST: Zip:
Patient Information
Please allow for 24 hours turnaround time before order will ship.
Incomplete orders may delay processing.
Shipping (check one)
FAX FORM TO: (855) 405-4669
I have reviewed my patient's medical record and determined the medication(s) / supplies ordered are medically necessary. I verify I have examined and diagnosed the patient as indicated above. I will comply
with state and federal documentation requirements by retaining a copy of this prescription in the patient's medical record. The prescription is to be dispensed as written unless otherwise instructed by me.
Prescriber Verification
If you need a medication not listed, please contact us at
844-446-6979
(toll-free)
Email Address:
FedEx Overnight
FedEx 2 Day
FedEx Ground
Bill to Office
Ship to Office
Ship to Patient
Bill to Patient
Atropine Sulfate 0.01%
Mydriatic 4
(Tropicamide/Proparacaine/Phenylephrine/Ketorolac
Tromethamine) 1/0.5/2.5/0.5%
**
Mydriatic 3
(Tropicamide/Cyclopentolate/Phenylephrine) 1/1/2.5%
Atropine Sulfate 0.025%
Atropine Sulfate 0.05%
Compounded Formulation*
Size/Volume #Refills Qty
Prescribers are reminded that state law allows patients to receive medications from a pharmacy of their choice.
Representative formulation. Please contact us for an alternate formulation. Customizable within certain ranges.
*For professional use only. ImprimisRx specializes in customizing medications to meet unique patient and practitioner needs. ImprimisRx dispenses these formulations only to individually identified patients
with valid prescriptions. No compounded medication is reviewed by the FDA for safety or efficacy. ImprimisRx does not compound copies of commercially available products. References available upon request.
**Shipped cold overnight.
Total prescriptions ordered:
To be administered
topically by the physician
Other:
To be administered
topically by the physician
Other:
1mL
5mL
Othe
r:
Topical Medications
Instructions for Use
(Required)
No commercial formulation
available.
Ot
Ot
her:
Mydriatic 2
(Tropicamide/Phenylephrine Hydrochloride) 1/2.5%
To be administered
topically by the physician
Other:
5mL
No commercial formulation
available.
he
No commercial formulation
available.
Other:
r:
No commercial formulation
available.
Other:
Other:
5mL
No commercial formulation
available.
5mL
No commercial formulation
available.
Other:
5mL
Medical Necessity
(Required)
QDOD
OS Other:
Prescriber Signature:
Prescriber Full Name:
State License #:
Date:
Phone:
DEA:
Email:
Office Contact:
NPI:
Fax:
Address: City:
ST: Zip:
Business/Clinic Name:
Ship to Address (if different from above):
City:
ST:
Zip:
New Credit Card Number: Expiration:
Billing Zip:
CVC/Code:
Doctor
Facility
Patient
Email Address:
Payor:
Method of Payment:
Credit Card on File Ending In: CVC/Code:
Keep on File
Invoice me using my PREAPPROVED Net-30 terms
Payment Information
ImprimisRx
®
Topical Order Form
Text:(858)264-2082 Chat:
imprimisrx.com
Email: order@imprimisrx.com
Medication Allergies (required)
DATE TO BE ADMINISTERED
NKDA
If allergies are not included,
the patient has NKDA.
QDOD
OS Other:
QDOD
OS Other:
First & Last Name Birthdate Address Known Drug Allergies
NKDA
Patient Information (All fields required)
Number of Refills: N/A
First & Last Name Birthdate Address Known Drug Allergies
NKDA
Number of Refills: N/A
First & Last Name Birthdate Address Known Drug Allergies
NKDA
Number of Refills: N/A
First & Last Name Birthdate Address Known Drug Allergies
NKDA
Number of Refills: N/A
First & Last Name Birthdate Address Known Drug Allergies
NKDA
Number of Refills: N/A
First & Last Name Birthdate Address Known Drug Allergies
NKDA
Number of Refills: N/A
First & Last Name Birthdate Address Known Drug Allergies
NKDA
Number of Refills: N/A
Current as of 7/2019 
PAGE 3
When shipping multiple patients' prescriptions together to a physician or clinic, please indicate "Earliest Date to be Administered" on order form Page 1 to determine ship date.
The pharmacy will plan for all orders to arrive by one day prior to these dates.
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Completed 16 April 2021

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