2000 Riverchase Ctr. Ste 675 Birmingham, AL (855) Phone (866) Fax

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1 2000 Riverchase Ctr. Ste 675 (855) Phone (866) Fax PHYSICIAN INTAKE FORM Sales Rep A1LA Physician Name: Clinic Name: Office Manager/Contact: Billing Address: City: State: Zip: Shipping Address: (Is it the same as Billing) Phone Number: Fax Number: Address: NPI#: DEA#: State License#: Shipping Methods Charged to Doctor/Clinic: Via FedEx Ground: 2 nd Day: Overnight: ***** PLEASE ATTACH COPY OF PHYSICIANS LICENSE AND DEA PERMIT****** Major Credit Cards Accepted: Credit Card Number: Expiration Date: Name on Card: Security Code: I acknowledge by signature on this form, the business I represent is accepting financial responsibility for goods delivered. Agreement for purchase of Compounded office use only medication. Medication can only be administered to patient by office staff, it is not to be dispensed to patient, and/or sold to any other person or entity. Signature Page 15

2 ADACEL VL 10X0.5ML AMOXICILLIN 500MG 500CT APLISOL 5TU 10 TEST VL 1ML APLISOL 5TU 50 TEST VL 5ML BETAMETHASONE ACET/NAPO4 6MG 5ML MDV BETAMETHASONE ACET/NAPO4 7MG 10ML BICILLIN CR MU A SYG 10X2ML BICILLIN LA 1.2 MU SYG 10X2ML BUPIVACAINE HCL 0.25% 50ML MDV 5.00 BUPIVACAINE HCL 0.5% 50ML MDV 4.00 BUPIVACAINE EPI 0.5% 50ML MDV 8.00 CEFAZOLIN 1GM(ANCEF) VL CEFOTAXIME (CLAFORAN) 1GM VL CEFTRIAXONE (ROCEPHIN) 1GM VL CEFTRIAXONE (ROCEPHIN) 250MG VL CEFTRIAXONE (ROCEPHIN) 500MG VL CLINDAMYCIN 300MG INJ 25X2ML CLINDAMYCIN 600MG SDV 25X4ML CLONIDINE HCL 0.1MG TAB DEPO ESTRADIOL 5MG/ML 5ML DEPO-MEDROL 40MG ML VL 10ML DEPO-MEDROL 80MG ML VL 5ML DEXAMETHASONE NAPO4 10MG 10ML MDV DEXAMETHASONE LA 8MG 10ML DEXAMETHASONE NAPO4 4MG ML 30ML MDV DIPHENHYDRAMINE HCL 50MG ML VL 25X1ML DIPHENHYDRAMINE HCL 50MG ML VL 10ML EPINEPHRINE 1MG ML AMP 25X1ML For additional items or questions, please call: or_fax to

3 EPINEPHRINE 1MG ML 30ML MDV ESTRADIOL VALERATE 40MG ML 5ML FUROSEMIDE 10MG ML 4ML 5.00 FUROSEMIDE 10ML 6.00 GARDASIL SDV HEPATITIS A ADULT HEPATITIS A PED HEPATITIS B ADULT HEPATITIS B PED KENALOG 10MG ML VL 5ML KENALOG 40MG ML VL 10ML KETOROLAC 30MG 10ML KETOROLAC 60MG 2ML SDV 25X2ML KETOROLAC 30MG ML SDV 25X1ML LIDOCAINE HCL 1% MDV 50ML 5.00 LIDOCAINE HCL 1% 1:100K EPI 50ML MDV 6.00 LIDOCAINE HCL 2% 50ML MDV 7.00 LIDOCAINE HCL 2% 1:100K EPI 50ML MDV 8.00 LIDOCAINE HCL VISCOUS 2% 100ML VL 5.00 LINCOCIN 300MG 10ML VL MARCAINE 0.5% 50ML MDV 7.00 MARCAINE 0.5% 1:200K EPI 50ML MDV METHYLPRED (DEPO MEDROL) 40MG 10ML METHYLPRED (DEPO MEDROL) 80MG 10ML MEDROXYPROGESTERONE 150MG 10ML MEDROXYPROGESTERONE 150MG ML 1ML SDV NALBUPHINE 10MG ML AMP 10X1ML NALBUPHINE 20MG ML AMP 10X1ML For additional items or questions, please call: or_fax to

4 ONDANSETRON 2MG ML SDV 25X2ML PHENYTOIN EXTENDED 100MG 100CAP PNEUMOVAX 23 VL 10X0.5ML PROMETHAZINE 25MG ML VL 25X1ML PROMETHAZINE 50MG ML 25X1ML SODIUM BICARB 8.4% VL 50ML SODIUM CHLORIDE 0.9% VL 50ML 5.00 SOLU-MEDROL 125MG AOV 2ML SOLU-MEDROL 1MG AOV 8ML SOLU-MEDROL 40MG AOV 1ML 7.00 TRIAMCINOLONE ACETONIDE 50MG 10ML TRIAMCINOLONE ACETONIDE 80MG 10ML TESTOSTERONE 200MG 10ML TETANUS/DIPTHERIA 10 PACK WATER STERILE FTV 50ML 6.00 WEIGHT LOSS VITAMIN B12 (CYANOCOLBALAMIN) 1100MCG 30ML VITACHROM 10ML VITACHROM 30ML For additional items or questions, please call: or_fax to

5 Vitachrom 10ml and 30ml vial Methionine: It assists in the breakdown of fats and thereby prevents the build-up of fat in the arteries, as well as assisting with the digestive system and removing heavy metals from the body since it can be converted to cysteine, which is a precursor to gluthione, which is of prime importance in detoxifying the liver. Inositol: Inositol plays an important part in the health of cell membranes especially the specialized cells in the brain, bone marrow, eyes and intestines. The function of the cell membranes is to regulate the contents of the cells, which makes effective functioning possible. Inositol is said to promote healthy hair, hair growth, and helps in controlling estrogen levels and may assist in preventing breast lumps.it may also be of benefit in reducing blood cholesterol levels. Choline Chloride: Choline is an essential nutrient required by the body to make several important compounds necessary for healthy cell membranes. This nutrient helps form phosphatidylcholine, the primary phospholipid of cell membranes. It helps transport of lipids from the liver. Choline is also the precursor to acetylcholine, one of the crucial brain chemicals involved in memory. Thiamine Hydrochloride: Thiamin (vitamin B1) helps the body's cells convert carbohydrates into energy. It is also essential for the functioning of the heart, muscles, and nervous system. Pyridoxine Hydrochloride: Pyridoxine, vitamin B6, is required by your body for utilization of energy in the foods you eat, production of red blood cells, and proper functioning of nerves. It is used to treat and prevent vitamin B6 deficiency resulting from poor diet, certain medications, and some medical conditions. Cyanocobalamin: Vitamin B12 plays an important role in red blood cells, prevention and treatment of anemia, methylation reactions, and immune system regulation. Chromium picolinate: Chromium is used for improving blood sugar control in people with prediabetes, type 1 and type 2 diabetes, and high blood sugar due to taking steroids. It is also used for depression, polycystic ovary syndrome (PCOS), lowering bad cholesterol, and raising good cholesterol in people taking heart medications called beta blockers