Fillable Fax ImprimisRx 855-405-4669 (ImprimisRx)

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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.
Medication Allergies
Preservative-Free Compounded Formulation*
Size/Volume
Topical Medications
Prescribers are reminded that state law allows patients to receive medications from a pharmacy of their choice.
**Shipped overnight cold.
Instructions for Use
# Refills
LAT PF
7.5mL
Qty
Tel: Home
Patient:
Age:
Work:
Address:
City:
M F
Cell:
DOB:
ST: Zip:
Patient Information
Shipping (check one)
Please allow for 72 hours turnaround time (3 business days) before order will ship.
Incomplete orders may delay processing.
Prescribing Physician Verification
Email Address:
If patient is unreachable, ship to verified address above
NKDA
If allergies are not included,
the patient has NKDA.
Total prescriptions ordered
If you need a medication not listed, please contact us at 844-446-6979 (toll-free).
TIM-LAT PF
5mL
BRIM-DOR PF
10mL
TIM-DOR-LAT PF
5mL
TIM-BRIM-DOR PF
5mL
(2 bottles
per shipment)
TIM-BRIM-DOR-LAT PF
5mL
TIM-BRIM-DOR-LAT PF
5mL
TIM-BRIM-DOR PF
5mL
OS
QHS
QD
BID
TIDOD
Additional fees apply for upgraded shipping.
Ship to:
Patient
Facility
1gtts
PF indicates preservative-free
Other:
Other
1 Bottle (7.5mL)
2
4
1
3
5
*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 essentially copies of commercially available products. References
available upon request.
Patient Clinical Information (please select one)
Ophthalmology
Other:
(Latanoprost, 0.005%)**
(Timolol/Latanoprost, 0.5/0.005%)**
(Brimonidine/Dorzolamide, 0.15/2%)
(Timolol/Dorzolamide/Latanoprost, 0.5/2/0.005%)**
(Timolol/Brimonidine/Dorzolamide, 0.5/0.15/2%)
(Timolol/Brimonidine/Dorzolamide/Latanoprost,
0.5/0.15/2/0.005%)**
(Timolol/Brimonidine/Dorzolamide, 0.5/0.15/2%)
(Timolol/Brimonidine/Dorzolamide/Latanoprost,
0.5/0.15/2/0.005%)**
DOR PF
10mL
(Dorzolamide, 2%)
OS QHS
QD
BID
TIDOD
Other
1 Bottle (10mL)
2
4
1
3
5
OS QHS
QD
BID
TIDOD
Other
1 Bottle (5mL)
2
4
1
3
5
OS QHS
QD
BID
TIDOD
Other
1 Bottle (10mL)
2
4
1
3
5
OS QHS
QD
BID
TIDOD
Other
1 Bottle (10mL)
2
4
1
3
5
OS QHS
QD
BID
TIDOD
Other
1 Bottle (5mL)
2
4
1
3
5
OS QHS
QD
BID
TIDOD
Other
2 Bottle (5mL)
2
4
1
3
5
OS QHS
QD
BID
TIDOD
Other
1 Bottle (5mL)
2
4
1
3
5
OS QAM
QD
BID
TIDOD
Other
1 Bottle (5mL)
2
4
1
3
5
OS QHS
QD
BID
TIDOD
Other
1 Bottle (5mL)
2
4
1
3
5
DOR-TIM PF
(Dorzolamide/Timolol, 2/0.5%)
10mL
Medical Necessity
(required)
Patient has trouble with multiple bottle regimen.
Patient needs preservative free.
Other:
Patient has trouble with multiple bottle regimen.
Other:
Commercial drug is not currently available to
my patient.
Patient has trouble with multiple bottle regimen.
Patient needs preservative free.
Other:
Patient has trouble with multiple bottle regimen.
Patient needs preservative free.
Other:
Patient has trouble with multiple bottle regimen.
Commercial drug is not currently available to
my patient.
Other:
Patient has trouble with multiple bottle regimen.
Patient needs preservative free.
Other:
Patient has trouble with multiple bottle regimen.
Patient needs preservative free.
Other:
Patient has trouble with multiple bottle regimen.
Patient needs preservative free.
Other:
Patient has trouble with multiple bottle regimen.
Patient needs preservative free.
Other:
Patient has trouble with multiple bottle regimen.
Patient needs preservative free.
Other:
Important: Patients may need to take more than one eye drop product pursuant to multiple dosing regimens, as
directed by his or her prescriber, in order for the active ingredients to remain effective throughout the day.
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.
FAX FORM TO: (855) 405-4669
Doctor Patient
Payor:
New Credit Card Number: Expiration:
Billing Zip:
CVC/Code:
Method of Payment:
Credit Card on File Ending In: CVC/Code:
Keep on File
Invoice me using my PREAPPROVED Net-30 terms
Prescriber Signature: Date:
Promo Code:
‡To pay by text, please provide a cellphone number
State License #: DEA:
Email:
NPI:
Prescriber Full Name: Phone:
Fax:
Address: City:
ST: Zip:
Office Contact:
Business/Clinic Name:
Ship to Address (if different from above):
City:
ST:
Zip:
Email Address: Cell Phone
‡
:
FedEx Overnight FedEx 2 Day FedEx Ground
Ship to Office Ship to Patient
Ophthalmic Topical Order Form
Text:(858)264-2082 Chat:
imprimisrx.com
Email: order@imprimisrx.com
DATE TO BE ADMINISTERED
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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