EAST: Fax: 702-791-3630 Phone: 702-791-3800
WEST: Fax: 702-685-3636 Phone: 702-685-3800
Date: ___________
 Mail to patient  Pick-up at pharmacy
 Deliver or mail to clinic – Need medication by_____________________
Name:
DOB:
Address:
City:
Home Phone: (
)
Other Phone: (
 Bill to Clinic
Billing Instructions:
State:
)
Zip:
Allergies:
 Charge Patient
Other Notes:
PRESCRIPTION ORDER FORM: (circle or check items ordered, indicate dose and dosage form)
REVITAPEL (Pellets):
 Testosterone _____________mg / lbs (pellet sizes:
 Estradiol _____________mg / lbs (pellet sizes:
Vaginal Applicators
 Estriol 0.5mg/gram
40, 55, 80, 100, 200 mg)
10, 12.5,15, 25, 50 mg)
 Use 1 applicator at bedtime
Dispense: #30
OR  Use 1 applicator three times per week at bedtime #12
 Estriol 0.5mg/gram + Testosterone 2mg/gram
 Trochar Kit
Use 1 applicator three times per week at bedtime
 Testosterone Cypionate Injection (200mg/ml)(grapeseed oil)
5ml
 DHEA Capsules
Inject intramuscularly once weekly
10mg
Alternate sig:____________________________
QTY:
 Bi-Est (80% Estriol, 20% Estradiol)
1.25mg
2.5mg
5.0mg
Refills:_______
Gel
Capsules
20mg
30mg
#60 Apply 1 gram daily OR Take 1 capsule daily
QTY:
10mg
25mg
QTY:
#30
Caps
50mg
#60
30mg
40mg
50mg
Sublingual
75mg
100mg
150mg
2mg
2mg 2.5mg 5mg 7.5 mg 10mg
15mg 50mg
#60
#30
Dissolve 1 tablet under the tongue at bedtime
QTY:
#30
1mg 2mg 3mg
Take one capsule by mouth at bedtime
Apply 1 gram daily OR Take 1 capsule
 Phosphatidyl Serine 250mg Capsules
 Add Pregnenolone 5mg per capsule
 Add Melatonin 1.5mg per capsule
QTY: #60 Sig: Take two capsules by mouth every evening
QTY: #______
Strength:______mcg: ______mcg
Sig:___________________________________
 T3- Capsules
Other_________
 Add Testosterone 2.5mg 5mg 7.5mg 10mg 20mg Other________
#30
Strength:______mcg
Sig:___________________________________
 Armour Thyroid Tablets 30mg 60mg 90mg 120mg
QTY: #30 Take 1 tablet by mouth every morning on empty stomach
 Transdermal methylation cream in topiclick container
MethylB12/HydroxoB12/Folinic acid/P5P/Vit-D 2mg/2mg/5mg/2mg/ 5000IU
30 grams
60 grams
Sig: Apply 0.5 gram (2 clicks) twice a day
Sig: Apply 1 gram (4 clicks) twice a day
 Notes / Other _________________________________________________________________________
PRESCRIBER SIGNATURE
Partell Specialty Pharmacy
20mg
Take 1 capsule up to 3 times a day as directed
 T4:T3- Capsules
 Add Progesterone 10mg 20mg 30mg 40mg 50mg Other_________
QTY:
15mg
 Melatonin Capsules
QTY: #______
4mg
10mg
 Add Pregnenolone 5mg per capsule
 Add Melatonin 1.5mg per capsule
QTY: #60 Sig: Take two capsules by mouth every evening
QTY:
3mg
7.5mg
Take 1 capsule by mouth daily at ____________
 Melatonin Sublingual Tabs 0.5mg 1.0mg 2.0mg 3.0mg
Other________
 Estradiol Cream Capsules
1mg
5mg
#30
QTY: #______
Suppositories
Other_________
30gm
60gm
Apply 1 gram daily
0.5mg
2.5mg
 L-Theanine 200mg Capsules
1 daily
 Testosterone Cream
 Cortisol Capsules ________mg
 Phosphatidyl Serine 250mg Capsules
Other__________
30gm
60gm
Apply 1 gram daily
 Progesterone
QTY:
20mg
Take 1 capsule by mouth daily
50mg 100mg 200mg 400mg Other_________
QTY: #30 Take 1 capsule by mouth daily
QTY:
10mg
100mg
50mg
40mg
Other________
 Progesterone Cream
75mg
 Pregnenolone Capsules
Other________
 Add Testosterone 1mg 2mg 2.5mg 5mg 7.5mg 10mg 20mg
QTY: #30
50mg
Lozenges
Other_________
 Add Progesterone 10mg
 7-Keto-DHEA
15mg 25mg
Other_______
#30
#12
PHONE / FAX
Refills__________________
DEA
EAST: 5835 S. Eastern Ave., #101 Las Vegas, NV 89119  Ph: 702-791-3800
WEST: 8751 W. Charleston Blvd., #120 Las Vegas, NV 89117  Ph: 702-685-3800
 Fax: 702-791-3630
 Fax: 702-685-3636
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