FAX: 888-247-6685

Doctor Name: Address: City: DEA#: Patient Name: Address: City: Person Faxing: Phone#: State: Med Lic#: Date of Birth: Phone#: State:
front & back):

-or-Scan: compoundingscripts@gmail.com
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PATIENT INSURANCE INFORMATION ( oryou may provide a copy of the patients card Insurance Carrier: Claim #: Group #:

W/C A djuster: BIN #: Pt ID #:

Phone: (

Patient Diagnosis:

LABEL RX IN SPANISH

TOPICAL ANALGESIC THERAPY CREAMS

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12.

BACLOFEN 2% - CYCLOBENZAPRINE 2% - KETOPROFEN 15% - LIDOCAINE 5% (BCKL)

(INFLAMMATION/SWELLING/PAIN RELIEF OF MUSCLES, TENDONS, LIGAMENTS, JOINTS, BONES MUSCLE SPASMS/STIFFNESS W/ LOCAL ANALGESIA)

BCKL DC102 DIL GKKL K20 MEDROX TEROCIN KC-5 DKGL 1 DKGL 2 DENDRACIN DMSO

DICLOFENAC 10% - CYCLOBENZAPRINE 2% (DC102)

(INFLAMMATION/SWELLING/PAIN/FEVER RELIEF OF MUSCLES, TENDONS, JOINTS RHEUMATISM)

DICLOFENAC 6% - INDOMETHACIN 6% - LIDOCAINE 5% (DIL)

(INFLAMMATION/SWELLING/PAIN RELIEF OF JOINTS, BONES, SOFT TISSUE WITH LOCAL ANALGESIA - ARTHRITIS - GOUT)

GABAPENTIN 10% - KETOPROFEN 10% - KETAMINE 10% - LIDOCAINE 5% (GKKL)

(INFLAMMATION/SWELLING/PAIN RELIEF OF JOINTS, BONES, SOFT TISSUE WITH LOCAL ANALGESIA NEUROPATHIC PAIN)

KETOPROFEN 20% - ULTRADERM BASE 120% (K20)

(INFLAMMATION/SWELLING/PAIN/FEVER RELIEF IN BODY ARTHRITIS RHEUMATISM OSTEOARTHRITIS TENDONITIS BURSITIS)

METHYL SALICYLATE 20% - MENTHOL 5% - CAPSAICIN 0.0375% (MEDROX OINTMENT)

(INFLAMMATION/PAIN RELIEF OF MUSCLES, JOINTS, NERVES IMPROVES FUNCTIONALITY & MOBILITY)

METHYL SALICYLATE 25% - CAPSAICIN 0.025% - MENTHOL 10% - LIDOCAINE 2.50% (TEROCIN LOTION)
(INFLAM./PAIN RELIEF OF MUSCLES/JOINTS ARTHRITIS/TENDONITIS STRAINS POSTHERPETIC NEURALGIA DIABETIC NEUROPATHY SHINGLES)

KETOPROFEN 10% - CAPSAICIN 0.05% - MENTHOL 5% - CAMPHOR 5% (KC-5)

(INFLAM./SWELLING/PAIN/FEVER RELIEF ARTHRITIS/TENDONITIS/OSTEOARTHRITIS RHEUMATISM BURSITIS DIABETIC NEUROPATHY NEURALGIAS)

DICLOFENAC 10% - KETAMINE 10% - GABAPENTIN 10% - LIDOCAINE 5% (DKGL 1)

(INFLAMMATION/SWELLING/PAIN RELIEF OF JOINTS, BONES, SOFT TISSUE ACUTE & NEUROPATHIC PAIN SCIATICA WITH LOCAL ANALGESIA)

DICLOFENAC 10% - KETOPROFEN 10% - GABAPENTIN 10% - LIDOCAINE 5% (DKGL 2)

(SAME AS DKGL1, BUT SUBSTITUTE KETOPROFEN FOR KETAMINE FOR JOINTS, BONES, SOFT TISSUE)

METHYL SALICYLATE 30% - MENTHOL 10% - CAPSAICIN 0.0375% (DENDRACIN)

(OSTEOARTHRITIS POSTHERPETIC NEURALGIA DIABETIC NEUROPATHY POST-MASTECTOMY PAIN)

KETOPROFEN 20% - DIMETHYL SULFOXIDE 5% (DMSO CREAM)

(INFLAMMATION/SWELLING/PAIN/FEVER RELIEF IN BODY ARTHRITIS RHEUMATISM OSTEOARTHRITIS TENDONITIS BURSITIS)

OTHER FORMULATIONS, ADDITIONS OR CHANGES:

*Please indicate Quantity:

120 GM

240 GM

Alternate Quantity

SIG: Apply 1-2 GRAMS to affected area 3-4 times daily. ALTERNATE SIG:
*NOTE: PLEASE CROSS OUT ANY UNWANTED MEDICATION IN ABOVE FORMULATIONS

PHYSICIAN SIGNATURE:

DATE:

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Valley View Drugs, Inc.

Ph: 866-941-1208

Fax: 8 8 8-247-6685