The Staff Pharmacy Over-The-Counter Order Form
NAME
PHONE
DATE
(OFF-SITE USE ONLY) DEPARTMENT:
This is an order form for over-the-counter items available for Memorial employees
and volunteers. All orders must be requested by faxing a copy of this completed
order form to the Staff Pharmacy. The items ordered will be available for pick-up at
the Staff Pharmacy two business days (Monday-Friday) after receiving your order.
If you work off-site you can make arrangements to have your order sent, via interoffice mail, by calling the Staff Pharmacy at 365-2525 with payment information.
Please indicate the quantity you request in the box located to the left of the item.
FAX TO THE STAFF PHARMACY: (719) 365-6252
Qty
Size
Compare to
Price
Item#
Prices valid thru 06/01/2014
COUGH AND COLD
AIRBORNE TABLET (VERY BERRY)
10
$7.20
4227880
CEPACOL (SENSATIONS)
20
$4.31
4562351
CORICIDIN HBP TAB CLD&FLU
20
$6.71
4315404
ST JOSEPHS HBP TAB
20
coricidin hbp flu
$7.31
4582292
DAYTIME COLD/FLU RELIEF
8oz
Dayquil
$4.02
4576740
COUGH DROPS HONEY/LEMON
25
Halls
$1.26
4348314
COUGH DROPS CHERRY
30
Halls
$1.26
4830824
COUGH DM
3oz
Delsym liquid
$6.50
4577920
EMERGEN-C
10
$4.92
4351458
MUCINEX 1200MG
14
$14.33
3990009
MUCINEX DM TABLET
20
$14.33
3592367
NASAL DECONGESTANT PE TABLET
18
Sudafed PE
$1.50
3637022
NASAL SPRAY EXT STRENGTH
0.5oz
Afrin
$1.14
3615341
NITETIME RELIEF (CHERRY)
10oz
Nyquil
$4.48
4577490
Q-TUSSIN
4oz
Robitussin Liquid
$1.35
2571602
Q-TUSSIN DM LIQUID
4oz
Robitussin DM Liquid
$1.44
2571644
VAPORUB JAR
3.53 OZ
Vicks Vapo Rub
$3.00
4351219
ZICAM COLD REMEDY TABS
25
$12.25
4294286
ALLERGY RELIEF
ALLER-EASE 180MG
30
allegra
$16.08
4344610
ALLERGY TABLET 4MG
100
Clortrimeton
$1.41
2302966
CHILDREN'S ALLERGY 1MG/ML SOLN
4oz
Zyrtec Syrup
$6.72
4029260
100
Zyrtec Tablets
$7.59
4576948
MHSP OTCALLERGY
ORDERTABLET
FORM10MG TABLET
1
BANOFEN TABS
100
Benadryl Minitabs
$2.58
3343258
LORATADINE 10MG TABLET
60
Claritin
$6.87
3513165
LORATADINE CHILD SYRUP
4oz
Claritin Syrup
$6.74
4373528
Q-DRYL
4oz
Bendaryl Syrup
$1.41
2755494
ASPIRIN EC TABLET 325MG
100
Ecotrin 325mg Tablet
$1.14
4556783
ACETAMENOPHEN 500MG CAPLET
100
Tylenol Ext Str 500mg
$1.74
2525871
ACETAMENOPHEN LIQUID CHERRY(MAPAP)
4oz
Tylenol Childrens Liquid
$3.65
4807335
ACETAMENOPHEN PM CAPSULE
50
Tylenol PM
$2.78
4350013
ASPIRIN EC TABLET 81MG
120
Ecotrin 81mg Tablet
$2.11
2533107
IBUPROFEN CHILDRENS LIQUID
4oz
Motrin Childrens Liquid
$5.52
4086849
IBUPROFEN TABLET 200MG
100
Motrin
$2.34
3035771
MIDOL MENSTRUAL COMPLETE
24
$7.38
2715464
Aleve Tablet
$6.62
3466455
excedrin extra strength
$3.75
3312154
ANALGESICS
NAPROXEN SOD 220MG(ALL DAY PAIN RELIEF) 100
100
MIGRAINE FORMULA
DIGESTIVE AIDS
ANTI-DIARRHEAL TABLET
12
Immodium
$2.25
1363068
PEG 3350
238gm
miralax
$6.66
4258323
ANTI-NAUSEA LIQUID CHERRY
4oz
Emetrol
$3.05
2312932
METAMUCIL TUB
30
$8.80
2972370
DOCUSATE 100MG
100
Colace
$2.72
1470475
SENNA TABLETS
100
Senokot
$3.15
2164416
ANTACID REGULAR STRENGTH (geri-lanta)
12oz
Maalox
$2.18
3203700
$3.40
1087477
MILK OF MAGNESIA
16oz
GAS RELIEF
100
Gas X
$2.18
2804144
OMEPRAZOLE 20MG TABLET
14
Prilosec
$10.48
4293858
PEPTO-BISMOL LIQUID
12oz
$6.50
1372499
ZANTAC 150MG
24
$12.37
3979416
PEPTIC RELIEF
30
$2.76
1697861
TUMS E-X 1-ROLL ASST
1 roll
$0.90
3030301
Pepto Bismol Chewable
CREAMS, OINTMENTS & LOTIONS
ANTI-ITCH CREAM
30
Benadryl Cream
$1.88
2372134
CLOTRIMAZOLE CREAM 1%
15 grams
Lortimin AF
$2.43
2311959
HYDROCORTISONE CREAM 1%
1oz
Cortaid Cream 1%
$1.89
2164150
ICY HOT ROLL- ON
85ml
$7.47
4119673
LUBRIDERM DAILY MOISTURIZER
6oz
$4.24
1985159
MICONAZOLE VAG 2% CREAM
48 gram
Monistat-7
$6.75
2582393
HEMORRHOIDAL OINTMENT
2oz
Preparation H
$3.84
2312940
BACITRACIN
1oz
$2.34
1559061
EYE CARE
ALLERGY EYE RELIEF
5ml
Alaway
$7.68
4301974
EYE DROPS 0.05%
15ml
Visine Eye Drops
$1.79
2260040
NATURAL BALANCE TEARS
15ml
Artificial Tears
$2.81
2412419
CONTACT LENS RINSE
118ML
Renu
$2.91
4227732
RENU LUBRICATING & REWETTING DROPS
8ml
$6.15
2823292
DENTAL CARE
ORAL ANALGESIC
12 gram
$1.87
4527156
DENTAL FLOSS WAXED 55YDS
1
$1.49
4216453
ORAL-B SATIN FLOSS
1
$3.54
2855724
LISTERINE POCKET PACK ARTIC BERRY/3CT
1
$5.57
4473419
SWORD FLOSS MINT
40
$2.00
2513901
2GM
$23.36
2986651
$1.39
2308708
orajel
LIP CARE
ABREVA
NATURAL ICE LIP BALM CHERRY
MHSP OTC ORDER FORM
2
VITAMINS
$5.75
4008579
$3.67
1121797
100
$2.00
2368843
GLUCOSAMINE&CHONDROITIN MSM
90
$9.67
3924115
MAGNESIUM OXIDE TABLET 400MG
120
$3.08
3551421
ONE DAILY VITAMINS
100
$1.79
4778007
SLOW-MAG TABLET
60
$5.45
3551330
VITABEE COMPLETE + C
100
$4.27
4263927
VIACTIV CALCIUM CHEW CHOCOLATE
60
$9.13
4545588
VIACTIV CALCIUM CHEW CARMEL
60
$9.13
4545547
VITAMIN C 500MG TABLET
100
$2.91
1430354
VITAMIN C CHEWABLE 500MG
100
$5.42
2236602
VITAMIN D 1000IU
100
$2.43
4345823
VITAMIN E 200IU
100
$4.68
2163004
VITAMIN E 400IU
75
$4.71
4062337
ALCOHOL PADS
100
$1.68
4390522
AYR SALINE NASAL GEL
AZO TABLETS
0.5oz
12
$4.70
$3.44
2385243
3318375
BAND-AID SHEER 40 COUNT
1
$2.75
4861928
BAND-AID SPONGE BOB
20
$3.48
3309309
PREGNANCY TEST 2 PAK
2
$7.05
2515583
ALWAYS INFINITY PADS (16)
1
$6.26
4580031
PILL REMINDER 7 DAY
1
$1.13
1513365
DEEP SEA NASAL SPRAY
45ml
Ocean Nasal Spray
$1.14
2163954
NICOTINE CLEAR PATCH 7MG
7
Nicoderm cq
$23.28
3734092
NICOTINE CLEAR PATCH 14MG
7
Nicoderm cq
$23.28
3734118
NICOTINE CLEAR PATCH 21MG
7
Nicoderm cq
$23.28
3733920
NICORELIEF ORIGINAL 2MG GUM
110
Nicorette gum
$30.99
3666591
NICORELIEF ORIGINAL 4MG GUM
50
Nicorette gum
$16.58
3593225
TABLET CUTTER
1
$2.80
3536125
TAMPAX REG/SUPER/LIGHT COMBO PK
40
$8.45
2807972
THERMOMETER DIGITAL (PROCHECK)
1
$2.52
4307252
THEROMOMETER PROBE COVERS (BD)
30
$1.79
4521357
OYSTER CALCIUM+D 500MG
100
MULTIVITAMIN SENIOR TABLET
60
FERROUS SULFATE 325MG
Centrum Silver
MISCELLANEOUS
TOTAL ITEMS
Azo Standard
SUB TOTAL
TAX
TOTAL
PAID BY:
CASH
CHECK
CREDIT
COMMENTS:
Memorial Hospital Staff Pharmacy
1400 E Boulder St.
Colorado Springs, CO 80909
Phone: 719-365-2525 Fax: 719-365-6252
AUTHORIZED SIGNATURE:
DATE:
MHSP OTC ORDER FORM
3