Compounded Medication Prescription
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Nutritional Compounding Order Form Patient’s Detail Name ____________________________________ Date of Birth _______________ Delivery Address _____________________________________________________________________________ Phone _________________ Fax _____________ AM Program Dose (elemental) Email ___________________________________________ PM Program Dose (elemental) Vitamin C corn-free mg Vitamin C corn-free mg Magnesium Ascorbate B6 P5P Carnitine mg mg mg mg Magnesium Ascorbate Zinc Picolinate Zinc Monomethionine Zinc Bis-glycinate mg mg mg mg CoQ10 Ferrous Bis-glycinate Vitamin E Succinate Vitamin E Mixed Tocopherol mg mg iu iu Zinc Citrate Manganese as Gluconate Vitamin E Succinate Vitamin E Mixed tocopherol mg iu iu iu Vitamin E Syn-soy free Biotin Cyanocobalamin B12 iu mcg mcg Vitamin E Syn soy-free Biotin Cyanocobalamin B12 iu mcg mcg Methylcobalamin B12 Folic Acid Folinic Acid 5-methyltetrahydrofolate mcg mcg mcg mcg Methylcobalamin B12 Folic Acid Folinic Acid 5-methyltetrahydrofolate mcg mcg mcg mg Niacinamide (Vit B3) Chromium Picolinate Chromium polynicotinate Methionine mg mcg mcg mg Niacinamide (Vit B3) Chromium Picolinate Chromium polynicotinate Methionine mcg mcg mg mg Betain (TMG) Calcium Citrate Magnesium Bis-Glycinate Magnesium Oxide mg mg mg mg Betain (TMG) Calcium Citrate Magnesium Bis-Glycinate Magnesium Oxide mg mg mg mg Taurine Vitamin A Beta Carotene Molybdenum mg iu iu mcg Taurine Vitamin A Beta Carotene Molybdenum iu iu mcg mcg Selenomethionine Vitamin D Serine Vitamin B1 mcg iu mg mg Selenomethionine Vitamin D Serine Ferrous Bis-glycinate Mcg iu mg mg Vitamin B2 Vitamin B2 activated Vitamin B5 mg mg mg GABA mg CAPSULES / POWDER / BOTH DAYS REQUIRED ___________ INOSITOL 500mg Capsules 100 x qty ____ SAMe 200mg AR capsules 100 x qty _____ Ca (500mg) /Mg (250mg) tablets 250 x qty _______ Allergies __________________ _______________________________ ____________________________________ Doctor Signature – Dispense as written Doctor Printed Name Creative Medicine Pharmacy 86 Bay St. Port Melbourne VIC 3207 Phone 03 9646 1947 _________________ Date pharmacist@creativepharmacy.com.au Fax 03 8677 1172
