|
|
|
| In order to receive more information about compounding,
please print out this request form and fax it to us at Creative
Compounding Center, fax number: 810-245-4133 or give us a call
at 1-800-672-2177. |
| Today's Date: |
|
| Prescriber's Name: |
|
| State License #: |
|
| DEA Number: |
|
| Address: |
|
| Telephone Number: |
|
| Fax Number: |
|
| Email Address: |
|
| Website: |
|
|
I hereby request that Creative Compounding Center Inc. send
me the following information on compounding and compounded
pharmaceuticals. I understand that compounded pharmaceuticals
are to be prescribed only for valid reasons of medical necessity
when the use of commercially available products, including
the off-label of commercially available products, is not adequate
or appropriate to treat the patient's condition. I further
agree that I will not copy, provide to third parties, or otherwise
disseminate any materials on compounding provided to me by
Creative Compounding Center Inc. without the pharmacy's express
permission.
|
| I would like general information on our compounding
abilities and/or information on the following specific medication. |
|
|
|
|
|
|
