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 TriMix Prescription Order


6700 Conroy Road, Ste 140 Fax: 407-673-1234
Orlando, FL 32835
407-673-2222
www.olympiapharmacy.com

Patient Information

Name: ___________________________________________________________________________Date: _________________

Address: __________________________________________City:_______________________ST:_________Zip:___________

Phone: _________________________________Email: ____________________________________ D.O.B. _______________

____ BiMix Inj (Papaverine 30mg / Phentolamine 1mg/ml)

____ TriMix Inj (Papaverine 30mg / Phentolamine 1mg / Alprostadil 10 mcg/ml) STANDARD FORMULA

____ Super TriMix Inj (Papaverine 30mg / Phentolamine 1mg / Alprostadil 25 mcg/ml)

____ QuadMix Inj (Papaverine 30mg/ml / Phentolamine 1mg/ml / Alprostadil 25mcg/ml / Atropine 0.2 mg/ml)

___ Custom Blend*


Papaverine _____ mg/ml Phentolamine _____ mg/ml Alprostadil _____ mcg/ml Atropine _____ mg/ml

Quantity ____: 5ml ____: 10ml _____: ml

Instructions: _______________________________________________________________________________

____ Other: 30 Syringes 1cc 30g 1/2” 100 Alcohol Swabs

____ Phenylephrine 1mg/ml 5ml

Ship to:

____ Office Address

____ Patient Address

Refills ___________________ ___________________________________________________


Physician Signature

___________________________________________________
Physician Phone