Prescriber. Address. Commonly prescribed for. (General Joint or Musculoskeletal Pain, Diabetic Peripheral Neuropathy. Combination

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1 information does not need to be repeated if already on file. Contact Person ing Form Anti-Inflammatory LidoVir AA-CMPD.1 V-CMPD 5 M-CMPD.3 Acyclovir 4% Increase Lidocaine 8% Add Benzocaine 3% (Osteoarthritis, Tendinitis, Plantar Fascitis) Amantadine 8% % Flurbiprofen 10% (General Joint or Musculoskeletal Pain, Diabetic Peripheral Neuropathy Lamotrigine 2.5% add % Combination Lidocaine Lotion 3% Lidocaine HCl 3% ZX-CMPD.1 Ketoprofen 10% Clonidine 0.2% Pentoxifylline 2% MN-CMPD 1 Gabapentin 3.8% Lidocaine 1.6% Prilocaine 1.6% Fenoprofen 8.3% Benzocaine 0.8% 10% US-CMPD1 MR-CMPD 1 Amitriptyline 2% Lidocaine 0.8% Prilocaine 0.8% Benzocaine 8% Loperamide 5% Meloxicam 0.9% Benzocaine 3% Neuropathic Pain ZB-CMPD.2 ZB-CMPD.3 (Diabetic or Chemo-induced Peripheral Neuropathy) % Nifedipine 2% (Shingles) % Acyclovir 5% HBK-CMPD.1 (Migraine) Sumatriptan 5% Doxepin HCI 5% Indomethacin 5% % Pain V-CMPD 10 Ketoprofen 20% Gabapentin 10% Dipentocaine Diclofenac 5% Lidocaine HCl 2% Sinelee Patch Capsaicin 0.05% Apply BID on (circle one): Relyyks Patch Apply BID on (circle one): Atendia Patch Menthol 3% Apply BID on (circle one): Pain Creams are Lipoderm based Qty: 120 GM. 240 GM. Other Provider Signature Date Refills Year NOTE: Check here if your patient does not wish to have a prescription auto-filled

2 information does not need to be repeated if already on file. Contact Person ing Form General Wellness WELL-C-CMPD Pyridoxial-5-Phosphate 25mg Methylcobalamin 2mg Folic Acid 5mg Methionine 12.5mg Choline Bitartrate 25mg Inositol 50mg SIG- Take 1 capsule twice daily before meals. Qty: 60 capsules Anti-itch Diphenhydramine 2.5% Zinc Acetate 0.2% Triamcinolone 0.1% Razor Burn Cream Hydrocortisone 1% Levocetirizine 1% Aloe 2% Bacitracin 200 units Neomycin 1.75 grams Polymixin B 2500 units Add Lidocaine 1% 400 mg NSAID Nalfon Qty: 90 capsules SIG- Take 1 capsule 3 times a day Skin Care G-CMPD 1 (Gout) Ketorolac 0.5% Colchicine 0.05% Indomethacin 2% Loperamide 1% TAC 0.1% Allergy ALLICURE (Sinusitis or allergic rhinitis) Levocetirizine 5% Fexofenadine 5% Resveratrol 1.67% Pracasil 2% SIG- Apply 1 pump to sinus area or thin skin once to twice daily as needed. Qty: 60 grams. DS-CMPD1 Dry Skin/ Psoriasis Hyaluronic Acid Sodium Salt in Versabase 0.2% 500 gm 1000 gm SIG - Apply 4-10 pumps 3-4 Alternative DS-CMPD2 Sodium Hyaluronic 0.2% in Versabase SIG - Apply 4-10 pumps 3-4 SC-CMPD 1 General Scar Therapy Hydrocortisone 0.5% Pentoxifylline 0.5% Levocetirizine 2% Gabapentin 15% Apply to affected area(s) twice daily WC-CMPD 5 Vancomycin 5% Mupirocin 5% Itraconazole 2% Wound & Scar S/W Patch Allantoin 2% Petrolatum 30% SSM-CMPD1 Alternative for Scar & Stretch Mark Therapy Tamoxifen 0.1% Pain Creams are Lipoderm based Qty: 120 GM. 240 GM. Other Provider Signature Date Refills Year NOTE: Check here if your patient does not wish to have a prescription auto-filled

3 FAX Your doctor has recommended and prescribed a compounded medication, which will be made to treat your specific needs. Every compounded prescription from Gardens Pharmacy is mixed specifically for you based on your condition and what your doctor has prescribed. THE PROCESS The pharmacy will receive the prescription from your doctor and enter the information into the computer system. A representative from the pharmacy will contact you, or your insurance provider, to verify your coverage. Any difficulties in confirming this information will delay the prescription from being mailed. Once this information is confirmed, your prescription will be shipped out and will arrive at your address in 1-2 business days. When you receive the medication it is important that you use your medication as directed by your doctor. If you have questions, or if Gardens Pharmacy has not contacted you after 24 hours from your prescription being turned in, please call (228) Powered by FAX

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5 Contact Person ing Form AA-CMPD.1 (Osteoarthritis, Tendinitis, Plantar Fascitis) Amantadine 8% Combination V-CMPD 5 Highest Ketamine % 10 Flurbiprofen 10% M-CMPD.3 (General Joint or Musculoskeletal Pain, Diabetic Peripheral Neuropathy Medicare Lamotrigine 2.5% add Tramadol % 2 LidoVir Pain Reliever Acyclovir 4% Increase Lidocaine 8% Add Benzocaine 3% Lidocaine Lotion 3% Lidocaine HCl 3% ZX-CMPD.1 Ketoprofen 10% Clonidine 0.2% Pentoxifylline 2% MN-CMPD 1 Medicare Gabapentin 3.8% Lidocaine 1.6% Prilocaine 1.6% Fenoprofen 8.3% Benzocaine 0.8% 10% Amitriptyline 2% Lidocaine 0.8% Prilocaine 0.8% Benzocaine 8% US-CMPD1 MR-CMPD 1 Muscle Relaxant Loperamide 5% Meloxicam 0.9% Benzocaine 3% Add Baclofen 1% for greater results Medicare 50/50 Neuropathic Pain ZB-CMPD.2 ZB-CMPD.3 (Shingles) (Diabetic or Chemo-induced Peripheral Neuropathy) Tramadol % 2 Tramadol 2 Nifedipine 2% % Acyclovir 5% HBK-CMPD.1 (Migraine) Sumatriptan 5% Doxepin HCI 5% Indomethacin 5% Tramadol % 2 Pain V-CMPD 10 Ketoprofen 20% Gabapentin 10% S/W Patch Allantoin 2% Petrolatum 30% Apply twice daily. Sinelee Patch Capsaicin 0.05% Apply BID on (circle one): Relyyks Patch change to Lidovir Apply BID on (circle one): Atendia Patch Menthol 3% Apply BID on (circle one): Pain Creams are Lipoderm based Qty: 120 GM. 240 GM. Other Year NOTE: Patch

6 Contact Person ing Form General Wellness WELL-C-CMPD Pyridoxial-5-Phosphate 25mg Methylcobalamin 2mg Folic Acid 5mg Methionine 12.5mg Choline Bitartrate 25mg Inositol 50mg SIG- Take 1 capsule twice daily before meals. Qty: 60 capsules Anti-itch Diphenhydramine 2.5% Zinc Acetate 0.2% Triamcinolone 0.1% Razor Burn Cream Hydrocortisone 1% Levocetirizine 1% Aloe 2% Bacitracin 200 units Neomycin 1.75 grams Polymixin B 2500 units Add Lidocaine 1% 400 mg NSAID Nalfon FDA Approved Qty: 90 capsules SIG- Take 1 capsule 3 times a day Skin Care G-CMPD 1 (Gout) Low out-of-pocket cost Ketorolac 0.5% Colchicine 0.05% Indomethacin 2% Loperamide 1% TAC 0.1% Allergy ALLICURE (Sinusitis or allergic rhinitis) Levocetirizine 5% Fexofenadine 5% Resveratrol 1.67% Pracasil 2% SIG- Apply 1 pump to sinus area or thin skin once to twice daily as needed. Qty: 60 grams. DS-CMPD1 Dry Skin/ Psoriasis Hyaluronic Acid Sodium Salt in Versabase 0.2% 500 gm 1000 gm SIG - Apply 4-10 pumps 3-4 Alternative DS-CMPD2 Sodium Hyaluronic 0.2% in Versabase SIG - Apply 4-10 pumps 3-4 SC-CMPD 1 General Scar Therapy Hydrocortisone 0.5% Pentoxifylline 0.5% Levocetirizine 2% Gabapentin 15% Apply to affected area(s) twice daily Wound & Scar WC-CMPD 5 Vancomycin 5% Mupirocin 5% Itraconazole 2% SSM-CMPD1 Alternative for Scar & Stretch Mark Therapy Tamoxifen 0.1% Dipentocaine Diclofenac 5% Lidocaine HCl 2% Pain Creams are Lipoderm based Qty: 120 GM. 240 GM. Other Year NOTE:

7 FOR THE PATIENT Your doctor has recommended and prescribed a compounded medication that will be made to treat your specific needs. Every prescription from the pharmacy is mixed specifically for you based on your condition and what your doctor has prescribed. THE PROCESS 1 The pharmacy will receive the prescription from your doctor and enter the information into the computer system. 2 A representative from the pharmacy may attempt to contact you or your insurance provider to verify your coverage. Any difficulties in confirming this information will delay the prescription being mailed out. 3 Once this information is confirmed, your prescription will be shipped out and will arrive at your address in hours. When you receive your prescription it is important that you use your medication as directed by your doctor. INSTRUCTIONS FOR APPLICATION WILL BE INCLUDED WITH YOUR PRESCRIPTION. questions: Call (877) Monday - Friday, 8:00a-5:00p CT. If you have not heard from the pharmacy or recieved your creams in three days, please call Gardens. Please do not call your doctor s office, as the pharmacy is responsible for filling your prescription. Powered by MEDKINE T I N N O V A T I V E E F F I C I E N T RESPONSIVE CAUTION: AVOID CONTACT WITH EYES AND/OR MOUTH. CREAM IS NOT TO BE INGESTED. FOR YOUR PATIENT S CONVENIENCE, WE WILL AUTO REFILL THIS PRESCRIPTION UNLESS OTHERWISE INDICATED.