PATIENT/
PRESCRIBER
FAMILY PLANNING REFERRAL FORM
PATIENT INFORMATION
First name:
PRESCRIBER INFORMATION
Last name:
Office name:
DOB:
Address:
Address:
City/State/Zip
City/State/Zip:
Primary phone:
Phone:
Fax:
ICD-9:
Cycle #:
Cycle Type:
IVF
Leuprolide Acetate 1 mg / 0.2ml (2 week kit)
qty (kits)
Sig:
(=
days)
refills
IUI
FET
Low Dose HCG
Sig:
Microdose Leuprolide Acetate
Sig:
(=
5 ml vial
qty
1 cc insulin syringes
Ovidrel 250 mcg prefilled syringes
Sig:
(=
days)
qty
qty
refills
refills
qty
refills
qty
Crinone 8% gel – 15 per box
Sig:
days)
qty
refills
mcg/
days)
½ cc insulin syringes
Ganirelix Acetate injection 250 mcg
Sig:
(=
Cetrotide
0.25 mg
3 mg
PRESC RIPT ION INFORMATION
SIGN AND FAX THIS FORM TO 877.828.3939
If you have questions, please call 877.627.MEDS (6337)
qty
days)
Sig:
Follistim AQ Cartridge
300
600
900 IU
(=
days)
Follistim pen
Sig:
Follistim AQ 75 IU
Follistim AQ 150 IU
(=
Sig:
(=
(=
days)
days)
g
900 IU
days)
(=
days)
Menopur 75 IU
(=
days)
3cc 22G 1 ½” syringe/needles #
Bravelle75 IU
IM
SC
Sig:
(=
g
days)
refills
qty (vials)
qty (vials)
refills
” needles
qty
qty
(=
days)
Sig:
Doxycycline 100 mg capsules
(=
days)
refills
qty
qty (vials)
refills
Sig:
Clomid 50 mg
Sig:
(=
days)
(=
days)
refills
qty
refills
2mg tablets
(=
days)
qty
refills
” needles
qty (vials)
refills
g
” needles
Pregnyl 10,000 IU
qty
refills
g
Endometrin vaginal tablet 100 mg
refills
qty
qty
days)
3cc 22G 1 ½” syringe/needles #
3cc 22G 1 ½” syringe/needles #
days)
(=
days)
Novarel 10,000 IU
(=
days)
Sig:
(=
Draw: 3cc 18G 1½” syringe/needles
Inject: 22G 1½” needles
qty
qty
qty
Sig:
Prometrium 200 mg capsules
Sig:
Medrol
mg tablets
” needles
qty (vials)
refills
HCG 10,000 IU
Sig:
Progesterone in sesame oil 50 mg/ml 10 ml vial
Progesterone in ethyl oleate 50 mg/ml 10 ml vial
Progesterone suppositories
mg
refills
qty (vials)
qty (vials)
qty (vials)
refills
3cc 22G 1 ½” syringe/needles #
Luveris 75 IU
IM
SC
Sig:
(=
g
(=
refills
qty
3cc 22G 1 ½” syringe/needles #
Gonal-f RFF Pen
300
450
Sig:
Gonal-f 450 IU multidose
Gonal-f 1050 IU multidose
Gonal-f RFF 75 IU
Sig:
Repronex 75 IU
IM SC
Sig:
ml
Provide copy of front and back of ins. card
10 IU/mL
20 IU/mL
qty
(=
days)
refills
” needles
Estrace
Sig:
1 mg
Estrace patch
Sig:
Desogen
Sig:
Other:
Sig:
Other:
Sig:
mg
Vivelle dot
(=
mg
days)
Mircette
(=
days)
(=
days)
(=
days)
refills
qty
refills
qty
qty
refills
qty
refills
qty
refills
qty
refills
PRESCRIBER SIGNATURE: PRESCRIBER SIGNATURE IS REQUIRED TO VALIDATE PRESCRIPTIONS.
Dispense as written/Do not substitute
Date
Substitution permitted/Brand exchange permitted
Date
For states requiring hand written expressions of product selection use this area (e.g. medically necessary, may not substitute, dispense as written, etc.).
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4951-C MT © Prime Therapeutics LLC 04/12 Prime Therapeutics Specialty Pharmacy LLC (Prime Specialty Pharmacy) is a wholly owned subsidiary of Prime Therapeutics LLC.