Medication Allergies
Patient Information
Orders with complete information will ship
within 24 hours (1 business day) of receipt.
Incomplete orders may delay processing.
Pursuant to VA/OH/MO/VT law. Only 1 medication is permitted per order form.
Please use a new form for additional items.
Shipping (check one)
Ship to Office
Ship to Patient
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. 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)
Tel: Home
Patient:
Age:
Work:
Address:
City:
M F
Cell:
DOB:
ST: Zip:
Email Address:
MRN#
Prescriber Signature:
Date:
Office Contact:
State License #: DEA:
Prescriber Specialty:
NPI:
Prescriber Full Name: Phone:
Fax:
Address: City:
St ate: Zip:
Email Address:
Shipping Method
Fedex Ground Fedex 2-Day
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
Fedex Priority Overnight
Patient Clinical Information
Ophthalmology
Other:
Payment Information
Facility
Payor:
Patient
Text:(858)264-2082 Chat:
imprimisrx.com
Email:info@imprimisrx.com
Total Tears
®
Order Form
DATE TO BE ADMINISTERED
NKDA
If allergies are not included,
the patient has NKDA.
Compounded Formulation*
Size/Volume
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)
RefillsQuantity
Total prescriptions ordered
*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.
Medical Necessity
(Required)
Klarity-L (Loteprednol 0.5% Ophthalmic
Suspension PF
)
Other _________________________
Klarity-C (Cyclosporine 0.1% Ophthalmic
Emulsion PF
)
5.5mL Bottle
5mL Bottle
5mL
Instill 1 drop, twice
daily as directed
Other:
Instill 1 drop, twice
daily as directed
Other:
Instill 1 drop, twice
daily as directed
Other:
Patient cannot tolerate
commercial formulation.
Other:
Patient cannot tolerate
commercial formulation.
Other:
Instill 1 drop, twice
daily as directed
Other:
Klarity Drops (Glycerin and Dextran
Based Vehicle Ophthalmic Solution PF)
10mL Bottle 10mL
1
2
3
4
5
6
7
8
9
10
11
No commercial product
available.
Other:
Klarity-A Drops (Azithromycin 1%
Ophthalmic Solution PF)
3.5mL Bottle
3.5mL
No commercial product
available.
Other:
1
2
3
4
5
6
7
8
9
10
11
1
2
3
4
5
6
7
8
9
10
11
1
2
3
4
5
6
7
8
9
10
11
5.5mL
16.5mL
