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imprimisrx.com
Email: order@imprimisrx.com
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MKO Melt
®
Order Form
Patient:
Age:
Work:
Address:
City:
Cell:
DOB:
ST: Zip:
Medication Allergies (required)
Patient Information
(Name, DOB, gender, address, phone required)
Please allow for 72 hours turnaround time (3 business days) before order will ship.
Incomplete orders may delay processing.
Shipping
Compounded Formulation
*
FAX FORM TO: (855) 405-4669
Prescriber Signature:
Prescriber Full Name:
State License #:
Date:
Phone:
DEA:
Email:
Office Contact:
NPI:
Fax:
Address:
City:
ST: Zip:
Instructions for Use Qty per patient
DATE TO BE ADMINISTERED
Business/Clinic Name:
Ship to Address (if different from above):
City:
ST: Zip:
Patient Profile(s)/Block Schedule Attached
Email Address:
Email Address:
Prescribers are reminded that state law allows patients to receive medications from a pharmacy of their choice
Representative formulation. Customizable within certain ranges. Please contact the pharmacist to discuss.
I have reviewed my patient’s medical record and determined the coumpounded 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.
Unused prescription medication should be discarded in conformance with all state and federal laws. The use of
a reverse distributor is recommended. Ensure to keep all accurate controlled substance records.
Dissolve sublingually prior to procedure
as instructed by prescriber.
Midazolam / Ketamine HCL/Ondansetron
Sublingual Lemon (3/25/2)mg
**
REMINDER: Please check patient information has been included before submitting.
Prescribing Physician Verification
If ordering for more than one patient, please use the attached form.
# of Patients _____
Patient requests to receive
prescription at prescriber ASC.
________
Staff initials required
If multiple prescribing physicians, use separate order form for each.
NKDA
Driver’s License or State Issued ID Number
†
:
**Shipped overnight cold.
†
Required patient information for the following states: Kentucky, Tennessee, Louisiana, Pennsylvania, Oklahoma, Kansas and Michigan.
*For professional use only. ImprimisRx specializes in customizing medications to meet unique patient and practitioner needs. ImprimisRx dispenses 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.
If allergies are not included,
the patient has NKDA.
If you need a medication not listed, please contact us at 844-446-6979 (toll-free).
Payment Information
New Credit Card Number: Expiration:
Billing Zip:
CVC/Code:
Doctor
Facility
Payor:
Method of Payment:
Credit Card on File Ending In: CVC/Code:
Keep on File
Invoice me using my PREAPPROVED Net-30 terms
Pursuant to VA/OH/MO/VT law. Only 1 medication is permitted per order form. Please use a new form for additional items.
Price
$16.50 per melt
Total prescriptions ordered: ___________
Patient Clinical Information
(please select one)
Ophthalmology
Other:
