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Download Dermatology Order Form
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Fax To: ImprimisRx Fax: 949-551-1950 From: Phone: 844-446-6979 Fax: Phone: Number of Pages: Date: Comments: PROTECTED HEALTH INFORMATION BUSINESS CONFIDENTIAL INFORMATION 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. Aesthetics & Dermatology Order Form Phone: (844) 446-6979 Fax: (949) 551-1950 Medication Allergies Patient Information Patient: Age: M Work: Address: City: Email Address: DOB: F Tel: Home Cell: ST: Shipping (check one) Zip: Please allow for 72 hours turnaround time (3 business days) before order will ship. Incomplete orders may delay processing. FedEx Overnight Bill to Office Bill to Patient FedEx 2 Day Ship to Office Ship to Patient FedEx Ground If you need a medication not listed, please contact us at 844-446-6979 (toll-free) Skin Formulations Size/Volume Instructions for Use DMAE 3%/Glycolic Acid 5%/Niacinamide 2%/Estriol 0.3%/Vit C 5% Cream 30gm Apply to cleansed face every night at bedtime Lipoic Acid 1%/CoQ10 0.5%/DMAE 3%/Hyaluronic Acid 0.5%/Vit E 50IU Cream 30gm Apply to cleansed face every night at bedtime Hyaluronic Acid 0.1% Serum 15mL Apply to a cleansed face AM and PM Hyaluronic Acid 0.2%/Aloe Vera 0.2% Mask 50gm Use once weekly as directed Vit C 6%/Urea 2%/Vit K 0.5%/Vit E 1% Under Eye Cream 15gm Apply every night to under eye area, do not rub Aloe Vera 0.2%/Vitamin C 2% Milk Cleanser) 120mL Wash face every morning and night as directed Gold Line Platinum Line Glutathione 1% in Peptide Base Cream 30gm Apply to cleansed face every night at bedtime Hyaluronic Acid 2% Serum (to be used with Derma Microneedle Roller) 10gm Use with micro roller at physician office as directed Latanoprost 50mcg/ml Solution 3 mL Apply to lash base every night at bedtime Typically Perscribed for Anti-Aging Anti-Oxidant Cream (Coenzyme Q10 1%) 30gm Apply to face twice a day Estriol Face Cream 2mg/gm 30gm Apply to wrinkle areas on the face every night DMAE/Niacinamide/Ascorbyl Palmitate/Glycolic Acid/Estriol 30gm Niacinamide 4% Gel 30gm Apply to face AM and PM Typically Prescribed for Rosacea Apply twice daily to affected areas Metronidazole 1%/Niacinamide 4%/Green Tea Extract 0.5%/Zinc Pyrithione 5% Lotion 30mL Metronidazole/Niacinamide Gel 30gm Lipoic Acid 10% Cream 30gm Apply to affected area on the face once to twice a day Azelaic Acid 20% Solution 30mL Apply to cleansed face every morning Qty # Refills If you need a medication not listed, please contact us at 844-446-6979 (toll-free) Skin Formulations Size/Volume Instructions for Use Typically Prescribed for Acne Tea Tree in Jajoba Oil 30mL Apply to cleansed skin twice daily, can be used as spot treatment in the AM Biotin 0.1% Lotion 30mL Apply day or night to cleansed skin Lipoic Acid 0.5%/Niacinamide 2%/Biotin 0.1% Cream 30gm Apply to cleansed skin AM and PM Cream Azelaic/Ascorbic Acid/Salicylic Acid Gel 30gm Apply to cleansed skin AM and PM Spironolactone 5%/Vitamin C 5% Gel 30gm Apply to cleansed skin of face once to twice daily Retinoic Acid/Niacinamide/Ascorbic Acid 30gm Salicylic Acid Cleanser 2% 60mL Salicylic Acid/Glycolic Acid Solution 60mL Spironolactone Cream/Solution 30mL Niacinamide Gel 30gm Peels Glycolic Acid High Purity ______% ____ mL Trichloroacetic Acid (TCA) ______% ____ mL Phenol USP Solution _______% ____ mL Jessner’s Solutions (Salicylic Acid 14%/Resorcinol 14%/Lactic Acid 14%) ____ mL Jessner’s Solutions (Salicylic Acid 7%/Resorcinol 7%/Lactic Acid 7%) ____ mL Ultra Jessner’s Solution (W/HQ 4%) Apply as directed Apply as directed Apply as directed Apply as directed Apply as directed 30mL Bleaching Alpha-Arbutin 2%/Retinoic Acid 0.025%/Hydrocortisone 0.25% Bleaching Cream Hydroquinone 6%/Retinoin Acid 0.1%/Hydrocortisone 1% in SiloMac 30gm ____ gm Apply daily as directed, use sunscreen Apply at bedtime or as directed for 30 days Apply at bedtime or as directed for 30 days Hydroquinone 6%/Ascorbic Acid 5% in SiloMac ____ gm Kojic Acid 4%/Arbutin 2% Serum in SiloMac ____ gm Apply at bedtime or as directed for 30 days Kojic Acid 8%/Arbutin 2%/Retinoic Acid 0.05% ____ gm Apply at bedtime or as directed for 30 days Retinoic Acid 0.1%/Ascorbic Acid 2% in SiloMac ____ gm Retinoic Acid 0.1%/Ascorbic Acid 5% in SiloMac ____ gm Apply at bedtime or as directed for 30 days Apply at bedtime or as directed for 30 days Typically Prescribed for Scar Therapy Dipenhydramine HCI 2%/Alpha Lipoic Acid 3%/Aloe Vera 0.5%/Vitamin E Acetate 1% Gel ____ gm Pentoxifylline 3%/Tranilast 1%/Caffeine 1%/Aloe Vera 0.5% Gel ____ gm Betamethasone Valerate 0.1%/Tranilast 1% Gel ____ gm Apply 2 to 3 times a day for 30 days EGCG 1%/Dimethylsufone 2%/Tranilast 1%/Ascorbic Acid 2%/Caffeine 1% Gel ____ gm Apply 2 to 3 times a day for 30 days Tretinoin 0.1% Gel ____ gm Apply 2 to 3 times a day for 30 days Niacinamide 3% Gel ____ gm Fluocinonide0.1% in SiloMac Base Gel ____ gm Apply 2 to 3 times a day for 30 days Apply 2 to 3 times a day for 30 days Apply 2 to 3 times a day for 30 days Apply 2 to 3 times a day for 30 days Typically Prescribed for Psoriasis Zinc Pyrithione 0.2%/Clobetasol 0.05% 120mL Apply 2 to 3 times a day Qty # Refills If you need a medication not listed, please contact us at 844-446-6979 (toll-free) Hair Formulations Size/Volume Instructions for Use Minoxidil 5%/Retinoic Acid 0.025% 120mL Apply at bedtime and wash off in the morning Minoxidil/Azelaic Acid/Retinoic Acid/Betamethasone 60mL Apply at bedtime and wash off in the morning Minoxidil/Finasteride Solution 60 mL Apply at bedtime and wash off in the morning Minoxidil/Dutasteride Solution 60mL Apply at bedtime and wash off in the morning Spironolactone/Minoxidil Solution 60mL Apply at bedtime and wash off in the morning Spironolactone 0.5%/Minoxidil 2% 120mL Apply at bedtime and wash off in the morning Spironolactone/Retinoic Acid Solution 60mL Apply at bedtime and wash off in the morning Dutasteride Solution 60mL Apply at bedtime and wash off in the morning Other Formulations Size/Volume Instructions for Use Qty # Refills Qty # Refills Anesthetic Benzocaine 20%/Lidocaine 8%/Tetracaine 6% in Plasticized Gel ____ gm Apply 20 to 30 minutes prior to desired effect Lidocaine 23%/Tetracaine 7% in Plasticized Gel ____ gm Apply 20 to 30 minutes prior to desired effect Lidocaine 7% in Plasticized Gel ____ gm Apply 20 to 30 minutes prior to desired effect Gabapentin 15%/Lidocaine 3%/Prilocaine 3% Gel ____ gm Apply 2 to 3 times a day for 30 days Anti-Fungal Fluconazole/DMSO Solution 15mL Apply to affected nails twice daily Terbenafine/DMSO Solution 15mL Apply to affected nails twice daily Total Number of Items Checked:________ Prescribing Physician Verification I have reviewed my patient's medical record and determined the 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 Full Name: State License #: Phone: DEA: Fax: NPI: Address: City: Business/Clinic Name: ST: Office Contact: Email Address: Prescriber Signature: Date: Payment Information Credit Card Number: Expiration: CVC/Code: FAX FORM TO: (949) 551-1950 Billing Zip: Zip:
