Name__________________________________________ Birth Date________________
Address________________________________________ Telephone________________
City______________________________ State____________ Zip________________
Medication Needed (check all that apply):
* * * * * * * * * * * * *
□ Estriol .5mg/.5ml Insert one applicatorfull vaginally at bedtime for 14 days then every
other day. REFILL: ______times or ______PRN for 1 year
_________________________________________________________________________
q Bi-Est 80/20 □ Tri-Est 80/10/10
______total mg □Topical □Oral (oil cap) □Sub Lingual Drop □Lozenge
Times per Day: □ QD □ BID □ TID □ QID □________
REFILL: ______times or ______PRN for 1 year
_________________________________________________________________________
Times per Day: □ QD □ BID □ TID □ QID □ ________
REFILL: ______times or ______PRN for 1 year
q Testosterone Micro (female) Topical (PLO)________mg/0.1ml To apply 0.1ml per dose
□ Testosterone Micro (female) ______mg □Sub Lingual Drop □Lozenge
REFILL: ______times or ______PRN for 6 months
q Testosterone Micro (male) Topical____mg/dose
□ Modified PLO base □ Fast absorption alcohol base
□ Testosterone Micro (male) ______mg □Sub Lingual Drop □Lozenge
Times per Day: □ QD □ BID □ TID □ QID □ _________
REFILL: ______times or ______PRN for 6 months
□ Combination of above (must be same dosage form and times per day)
□ Estrogen □ Progesterone □ Testosterone
_________________________________________________________________________
Doctors Name ____________________DEA#_____________Telephone _______________
Address__________________________City___________ State __________ Zip ______
Doctor’s Signature_____________________________________ Date_______________