EMERSON PHARMACY

8400 Lincoln Blvd. Los Angeles, CA 90045

Phone: (310) 670-3833 Fax: (310) 670-4921

COMPOUND PRESCRIPTION FORM

Patient Name: Phone Number:

Address: City: State: CA Zip Code:

Arthritis/Pain (Cream) #60 gm Sig: Apply 1 gm to affected nail BID

Number of Refills:
 Voltaren Gel: (Diclofenac 3%, Cyclobenzaprine 1%, Lidocain Anti-Nausea
5%, Gabapentin 6%, Hyaluronic acid 1%)

NSAIDS
#90 gm Sig: AAA TID Number of Refills:  Zofran 10 mg Troche:
# 30 Sig: 1 Q 4-6 H PRN N/V

 Celerelief: (Celebrex 50mg, Hyaluronic Acid 10mg) Acne

Number of Refills:

#30 Sig: 1 QD Number of Refills:

Arthritis/Pain (Oral)  Acne/Fol Soloution: (Azelaic Acid 3%, Salicylic Acid 3%,
 Pain-ease: (Hydrocodone 5, 7.5, 10 mg, Hyaluronic Acid Niacinamide 4%, Hydrocortisone 1%, Clindamycin 1%)
#60 ml Sig: Apply to acne spot BID
5 mg, Diclofenac 25 mg) Acne Cream: (Salicylic Acid 2%, Zinc Acetate, Resorcinol,
#90 Sig: 1 Q H PRN Pain Number of Refills: Niacinamide, Lipoic Acid, Hydrocortisone 1%)
Muscle Relaxers # #60 gm Sig: Apply all over the face BID 20 minute AFTER


applying the Acne/Fol Solution
Muslax SR: (Cyclobenzaprine 5 Number of Refills:
mg, Diclofenac 35mg, Anti-Wrinkle

 Enhanced Renova 0.05% Cream: (Hyaluronic

Hyaluronic Acid 5 mg)
#60 Sig: 1 BID Number of Refills:

 Slax SR: (Skelaxin 200mg,

Acid, Retinoic Acid 0.05%, Estriol 0.3%, Vitamin A, C, E,
TMC or Synalar 0.01%, Kinetin)
Diclofenac, 25 mg, Hyaluronic Acid # 30 gm Sig: Apply HS
5mg) Anti-Oxidant Cream: (Hyaluronic Acid, Astaxanthin 0.01%,
#120 Sig: 1 QID Number of Refills Lipoic Acid 0.5%, Green Tea Extract, Vitamin A, C, E, K,
Migraines Tazoratene 0.01%, Hyaluronic Acid)
#30 gm Sig: Apply QAM
 Solmig: (Imitrex 25mg, Ibuprofen Revitalizing Eye Cream: (Eyliss, Argeriline, Hyaluronic
Acid, Vitamin A, C, E, K)
600mg) #30 gm Sig: Apply around the eyes QD
#9 Sig: 1 QD PRN Number of Refills:
Hydrate ME Complex Serum:
 Fioerg: (Fioricet, Ergotem 0.1 mg) Sig: Apply before the Anti-Oxidant Cream in AM
Number of Refills:
#100 Sig: 1 Q 4-6 H Number of Refills: Integument Rx
Psoriasis

 Betaderm Spray: (Derma Zinc, Clobetasol 0.05%)
#60 ccSig: Spray to affected area BID
Acne Lotion: (Coal Tar 5%, Salacid 3%, TMC 0.1%)
#60 gm Sig: Apply ½ hour after the spray BID
Number of Refills:
Anti-Fungal (Pink Nail)
 Bleaching Cream: (Lita-max: Hydroquinone 6%, Kojic
Acid 3%, Retinoic Acid 0.05%, HC 1%, Fluocinonide 0.001%)
# 60 gm Sig: AAA QHS Number of Refill
 Rosacea Cream: (Metronidazole 1%, Sulfacetamid 10%,
Hyaluronic Acid 0.5%) # 60 gm
Sig: AAA followed by sunscreen Number of Refills:

 Fungaremove Ointment:  Step-Revitalize Peel 50%:

(Lamisil 1.5% Salicylic Acid 6%, # 30 ml Sig: Apply Q 3 WKS Number of Refills:
Diflucan 1.2%, Loprox 30%, Neosporin
56%, Hydrocortisone 2.5%)
Physician: Signature: Date: