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Ophthalmic Injectable Order Form
Patient:
Age:
Work:
Address:
City:
M F
Cell:
DOB:
ST: Zip:
Medication Allergies (required)
Patient Information (Name, DOB, gender, address required)
Please allow for 72 hours turnaround time (3 business days) before order will ship.
Incomplete orders may delay processing.
Shipping (check one)
FedEx Overnight FedEx 2 Day
FedEx Ground
Compounded Formulation*
FAX FORM TO: (855) 405-4669
I have reviewed my patient's medical record and determined the compounded medication(s) / supplies ordered are medically necessary and that an FDA approved drug is not medically appropriate. 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.
Prescribing Physician Verification
Prescriber Signature:
Prescriber Full Name:
State License #:
Date:
Phone:
DEA:
Email:
Office Contact:
NPI:
Fax:
Address: City:
ST: Zip:
If you need a medication not listed, please contact us at 844-446-6979 (toll-free).
Size/Volume
Injectable Medications -
Available from 503B or (503A in AR, AL only)
**Shipped cold overnight.
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.
Instructions for Use (Required) Qty
Tri-Moxi (Triamcinolone Acetonide and Moxifloxacin
Hydrochloride) 15/1mg/mL
1 vial
Lidocaine/Epinephrine in BSS (PF/SF)** 0.75/0.025%
1 vial
Intravitreal injection to be administered by
physician.
Dex-Moxi (Dexamethasone Sodium Phosphate,
Moxifloxacin Hydrochloride) 1mg/5mg/mL
Moxifloxacin 5mg/mL
Phenylephrine/Lidocaine (PF) 1.5/1%
1 vial
1 vial
1 vial
1 vial
Other
DATE TO BE ADMINISTERED
Business/Clinic Name:
Ship to Address (if different from above):
City:
ST:
Zip:
Patient Profile(s)/Block Schedule Attached
New Credit Card Number: Expiration:
Billing Zip:
CVC/Code:
Doctor
Facility
Patient
Email Address:
Email Address:
Total prescriptions ordered
Pursuant to VA/OH/MO/VT law. Only 1 medication is permitted per order form. Please use a new form for additional items.
Payor:
Method of Payment:
Credit Card on File Ending In: CVC/Code:
Keep on File
Invoice me using my PREAPPROVED Net-30 terms
Dex-Moxi-Ketor (Dexamethasone Sodium Phosphate,
Moxifloxacin Hydrochloride and Ketorolac) 1mg/0.5mg/0.4mg/mL
Other:
*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.
Patient Clinical Information (please select one)
Ophthalmology
Other:
Payment Information
NKDA
If allergies are not included,
the patient has NKDA.
