Patient Demographics Form 2

PATIENT DEMOGRAPHICS

DOB:

Phone Number:

NAIL REMOVER

Allergies:

DUrea 40% Occlusive Ointment

DUreci 40%/Bacitracin SOOU/Gm/Clotrimazole 2%/Ibuprofen 2%/Deoxg-D—
Glucose 0.19% Topical Ointment

FUNGAL SKIN INFECTIONS
E|l

15g or 30g
Refills:

30g or 30mL

R i’ll :
ElCIotrimazole 2%/Ibuprofen 2%/Tea Tree Oil 1%Topical Cream el 3
NAIL FUNGUS
Ci ltraconazole1%/ibuprofen 2%/DMSO Nail Solution I5mI- 0*’ 3OmL
iji Terbinafine1.67%/lbuprofen2% DMSO Nail Solution Refillsij
El ltraconazole1%/Terbinafine I-lC| 3%/Tea Tree Oil 6.6%/Urea 10%/Biotin
0.6%/DMSO Nail Suspension
CIRCULATORY PROBLEMS/RAYNAUD’$ PHENOMENON
3Nifedipine 4% TopicalCream 30g 0, 609
3Nifedipine16% Topical Cream Remlsz

U Pentoxiiglline 5%/Nifedipine 2% Topical Cream

DIABETIC NEUROPATHY

D Ketamine10%/Gabapentin 6%/Tizanidine 0.2%/Nifedipine 2% Topical Cream

DAmitriptg|ine 2%/ Bacioten 2% Topical Cream

30g or 60g

DAmitriptg|ine 2%/ Baclofen 2%/ Ketamine 5%/ Ketoprofen 10% Topical Cream Refmam

FOOT CRAMPS

l]Guaifenesin 10% Topical Cream

CI Magnesium Chloride iO%/ Peppermint 1% Topical Cream 309 0’ 509
Refills:

El Guaifenesin 10%/ Magnesium sulfate heptahgdrate 10% Topical Cream

PLANTAR FASCIITIS

£]Diclofenac10%/ibuprofen 2%/Cgclobenzaprine 2%/ Magnesium 5%
i]Diclofenac10%/ibuprofen 2%/ Cgclobenazeprine 2% Cream

30g or (309
Refills:

DFlurbiprofen10%/Cgclobenazeprine1%/Gabapentin 6%/ Lidocaine 2%/

Prilocaine 2% Topical Cream

HYPERHIDROSIS

DGlgcopgrro|ate 1% Topical Cream
CiGlgcopgrrolate 0.5% Topical Roll’On solution

Pngsician Signature:

30g or 30mL
Refills:

Date:

Physician Printed name:

Check box if substitutions are permitted