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Fax ImprimisRx 855-405-4669 (ImprimisRx)

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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.
Ophthalmic Topical Order Form
Medication Allergies (required)
Shipping (check one)
FedEx Overnight FedEx 2 Day
FedEx Ground
Ship to Office Ship to Patient
Combination Formulations*
Size/Volume
Instructions for Use
(Required)
# RefillsQty
Medical Necessity
(Required)
DATE TO BE ADMINISTERED
Tel: Home
Patient:
Age:
Work:
Address:
City:
M F
Cell:
DOB:
ST: Zip:
Patient Information (Name, DOB, gender, address required)
Orders with complete information will ship within 24 hours (1 business day) of receipt.
Patient profile(s)/block schedule attached
Email Address:
If patient is unreachable, ship to verified address above
NKDA
If allergies are not included,
the patient has NKDA.
Pursuant to VA/OH/MO/VT law. Only 1 medication is permitted per order form. Please use a new form for additional items.
Incomplete orders may delay processing.
If you need a medication not listed, please contact us at 844-446-6979 (toll-free).
Patient Clinical Information (please select one)
Ophthalmology
Other:
Total prescriptions ordered
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.
Prescribing Physician Verification
Prescriber Signature: Date:
State License #: DEA:
Email:
NPI:
Prescriber Full Name: Phone
:
Fax:
Office Contact
:
Business/Clinic Name:
Address: City:
ST: Zip:
Ship to Address (if different from above):
City:
ST:
Email Address:
Payment Information
Doctor
Facility
Payor:
Patient
Method of Payment:
New Credit Card Number: Expiration:
Billing Zip:
CVC/Code:
Credit Card on File Ending In: CVC/Code:
Keep on File
Invoice me using my PREAPPROVED Net-30 terms
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.
Zip:
FAX FORM TO: (855) 405-4669
*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.
†
Email: order@imprimisrx.com
Text:
(858)264-2082 Chat:
imprimisrx.com
Other:
No commercial formulation available.
Pred-Gati (Prednisolone Acetate/Gatifloxacin) (1/0.5)%
5mL
Patient has trouble with multiple
bottle regimen.
Other:
Patient has trouble with multiple
bottle regimen.
Other:
Patient has trouble with multiple
bottle regimen.
Other:
Pred-Gati-Brom (Prednisolone Acetate/Gatifloxacin/Bromfenac)
(1/0.5/0.075)%
Pred-Moxi-Brom (Prednisolone Acetate/Moxifloxacin/Bromfenac)
(1/0.5/0.075)%
Pred-Gati-Brom (Prednisolone Phosphate/Gatifloxacin/Bromfenac)
(1/0.5/0.075)%
5mL
Pred-Brom (Prednisolone Acetate/Bromfenac) (1/0.075)%
Patient has trouble with multiple
bottle regimen.
Other:
Pred-Moxi-Nepaf (Prednisolone Acetate/Moxifloxacin/Nepafenac)
(1/0.5/0.1)%
Pred-Moxi (Prednisolone Acetate/Moxifloxacin) (1/0.5)%
OS
QID
TID
OD
OS
QID
TID
OD
Other:
Patient has trouble with multiple
bottle regimen.
Other:
5mL
Patient has trouble with multiple
bottle regimen.
Other:
5mL
8mL
5mL
8mL
5mL
8mL
Patient has trouble with multiple
bottle regimen.
Other:
5mL
8mL
5mL
Prednisolone Acetate Preservative-Free 1%
OS
QID
TID
OD
OS
QID
TID
OD
OS
QID
TID
OD
OS
QID
TID
OD
OS
QID
TID
OD
OS
QID
TID
OD
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 18 April 2021

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