Drug Services Compounding Order Form
For Pharmacies Only
Name
*
First Name
Last Name
Ordering Pharmacy
*
Please Select
Eastside Specialty Clinic Pharmacy
Fred Hutch Cancer Care Pharmacy
Harborview Inpatient Pharmacy
Harborview Outpatient Pharmacy
IDS (Montlake)
International Clinic Pharmacy (HMC)
Madison Clinic Pharmacy (HMC)
Ninth and Jefferson Pharmacy (HMC)
Northwest Inpatient Pharmacy (UWMC)
NW Outpatient Pharmacy (UWMC)
Pat Steel Pharmacy (HMC)
Pioneer Square Clinic Pharmacy (HMC)
Roosevelt Pharmacy (UWMC)
UWMC Inpatient Pharmacy
UWMC ML Outpatient Pharmacy
Email
*
example@uw.edu
2nd Email
example@uw.edu
Item 1
Medication
*
Please Select
DS 123 Paste Topical 30gm
DS Acetazolamide 25mg/mL suspension
DS Acetic Acid 1% Solution 480mL
DS Acetic Acid 10% Solution 480mL
DS Acetic Acid 3% Solution 480mL
DS Acetic Acid 4% Solution 480mL
DS Acetylcholine 10% Topical Solution 10mL
DS Amiodarone 5mg/mL Suspension 400mL
DS Amphotericin B 100mg/mL oral suspension 300mL
DS Aspirin 300mg suppository
DS Azathioprine 5mg/mL suspension
DS B.I.P Ointment 85gm
DS Baclofen 5mg/mL Suspension
DS Beclomethasone (BDP) 1mg/mL in Corn Oil 500mL
DS Bevacizumab 3.75mg/0.15mL Syringe
DS Boric Acid 600mg Topical Capsule
DS Boric Acid-Polymyxin B Ear Powder 200mg
DS Boric Alcohol Ear Drops
DS Brilliant Green 5% Topical Solution 30mL
DS Budesonide 1mg/mL Suspension
DS Busulfan 10mg Capsules
DS Butyrate Enema 1000mL
DS Chlorhexidine Gluconate 0.04% OPHTHALMIC solution
DS Clobetasol Propionate 0.05% Oral Rinse Solution
DS Clonidine HCL 0.01mg/mL NICU Suspension
DS Cyclophosphamide 10mg/mL suspension
DS Cyclosporine 2% OPHTHALMIC solution 5mL
DS dexAMETHasone 1mg/mL suspension 100mL
DS Dexamethasone 24mg/mL OTIC inj 3mL
DS Diltiazem 2% in Zinc Oxide 30gm
DS EDTA Disodium 2% OPHTHALMIC solution 15mL
DS Estrogen, Conjugated Nasal Spray 0.67mg/mL 30mL
DS Flucytosine 50mg/mL Suspension 480mL
DS Formula #2 mouthwash (Aminocaporate 5% base solution) 80mL
DS Glycerin 50% Oral Solution 240mL
DS hydroCHLOROthiazide 5mg/mL suspension 100mL
DS Hydrocortisone 1% / Nystatin 0.5% in Zinc Oxide
DS Hydrocortisone 2mg/mL Suspension
DS Hydrocortisone Vaginal Suppository 100mg in Pegblend 12's
DS Hydroxychloroquine Sulfate 25mg/mL suspension
DS Hydroxyurea 100mg/mL Suspension
DS Indigo Carmine Powder 100mg (Non-Sterile)
DS Iodine Tincture 1% 240mL
DS Isradipine 1mg/mL Suspension
DS Ketamine 4mg/mL suspension
DS LCD 5% in Aquaphor
DS LCD 20% in Ethyl Alcohol Absolute
DS Lidocaine 4% Nasal Spray 25mL
DS Lisinopril 1mg/mL Suspension
DS Magic Numbing Gel 1.5mL Syringe
DS Methoxsalen 0.3% in Alcohol and Propylene Glycol 30mL
DS Metoprolol 10mg/mL Suspension 480mL
DS Morphine Sulfate Oral Solution 400mcg/mL (NICU) 100mL
DS Moxifloxacin 20mg/mL suspension
DS Mupirocin 0.03% Nasal Irrigation solution 1000mL
DS Mupirocin 0.2% Nasal Spray 25mL
DS Nifedipine 0.2% & Lidocaine HCL 1.5% Topical Gel
DS Nifedipine 0.2% Gel
DS Nimodipine 30mg/mL Suspension
DS Nipple Ointment 30gm
DS Nitroglycerin 0.2% Ointment 30gm
DS Oxytocin 10units/mL Nasal Spray 5mL
DS Patch Test in White Petrolatum
DS Phytonadione 1mg/mL Oral Liquid 240mL
DS Pyrazinamide 100mg/mL suspension
DS Pyrazinamide 10mg/mL suspension
DS Ribavirin 40mg/mL Suspension
DS Rifampin 25mg/mL Suspension
DS Rifampin 50mg/mL Suspension
DS Sodium Benzoate 250mg/mL oral solution
DS Sodium Chloride 2.5mEq/mL solution 250mL
DS Squaric Acid Dibutylester in Acetone 0.5% 10mL
DS Squaric Acid Dibutylester in Acetone 2% 10mL
DS Sucralfate Enema 100mg/mL
DS Sulfacetamide 15% in 50% Ethanol Topical Solution
DS Sulfasalazine 100mg/mL Suspension
DS Tacrolimus 1mg/mL Suspension 240mL
DS Thymol 3% in 70% Ethanol 30mL
DS Toluidine Blue 1% Solution 30mL
DS Tretinoin 10mg/mL in Soybean Oil (Oleaginous oral Susp) 100mL
DS Trichloroacetic Acid 85% Solution 10mL
DS Ursodiol 25mg/mL Suspension 480mL
DS Ursodiol 25mg/mL Suspension W/TABLETS 480mL
DS Zinc Acetate 10mg/mL (Elemental Zinc) Syrup 100mL
Pick from Dropdown
Medication Not Listed
Medication
Freetext (Drug Name, Strength, Formulation)
Medication Size
Qty Needed
*
If 10 suppositories needed, write "10."
Item 2
Medication 2
Please Select
DS 123 Paste Topical 30gm
DS Acetazolamide 25mg/mL suspension
DS Acetic Acid 1% Solution 480mL
DS Acetic Acid 10% Solution 480mL
DS Acetic Acid 3% Solution 480mL
DS Acetic Acid 4% Solution 480mL
DS Acetylcholine 10% Topical Solution 10mL
DS Amiodarone 5mg/mL Suspension 400mL
DS Amphotericin B 100mg/mL oral suspension 300mL
DS Aspirin 300mg suppository
DS Azathioprine 5mg/mL suspension
DS B.I.P Ointment 85gm
DS Baclofen 5mg/mL Suspension
DS Beclomethasone (BDP) 1mg/mL in Corn Oil 500mL
DS Bevacizumab 3.75mg/0.15mL Syringe
DS Boric Acid 600mg Topical Capsule
DS Boric Acid-Polymyxin B Ear Powder 200mg
DS Boric Alcohol Ear Drops
DS Brilliant Green 5% Topical Solution 30mL
DS Budesonide 1mg/mL Suspension
DS Busulfan 10mg Capsules
DS Butyrate Enema 1000mL
DS Clobetasol Propionate 0.05% Oral Rinse Solution
DS Clonidine HCL 0.01mg/mL NICU Suspension
DS Cyclophosphamide 10mg/mL suspension
DS Cyclosporine 2% OPHTHALMIC solution 5mL
DS dexAMETHasone 1mg/mL suspension 100mL
DS Dexamethasone 24mg/mL OTIC inj 3mL
DS Diltiazem 2% in Zinc Oxide 30gm
DS EDTA Disodium 2% OPHTHALMIC solution 15mL
DS Estrogen, Conjugated Nasal Spray 0.67mg/mL 30mL
DS Flucytosine 50mg/mL Suspension 480mL
DS Formula #2 mouthwash (Aminocaporate 5% base solution) 80mL
DS Glycerin 50% Oral Solution 240mL
DS hydroCHLOROthiazide 5mg/mL suspension 100mL
DS Hydrocortisone 1% / Nystatin 0.5% in Zinc Oxide
DS Hydrocortisone 2mg/mL Suspension
DS Hydrocortisone Vaginal Suppository 100mg in Pegblend 12's
DS Hydroxychloroquine Sulfate 25mg/mL suspension
DS Hydroxyurea 100mg/mL Suspension
DS Indigo Carmine Powder 100mg (Non-Sterile)
DS Iodine Tincture 1% 240mL
DS Isradipine 1mg/mL Suspension
DS Ketamine 4mg/mL suspension
DS LCD 5% in Aquaphor
DS LCD 20% in Ethyl Alcohol Absolute
DS Lidocaine 4% Nasal Spray 25mL
DS Lisinopril 1mg/mL Suspension
DS Magic Numbing Gel 1.5mL Syringe
DS Methoxsalen 0.3% in Alcohol and Propylene Glycol 30mL
DS Metoprolol 10mg/mL Suspension 480mL
DS Morphine Sulfate Oral Solution 400mcg/mL (NICU) 100mL
DS Moxifloxacin 20mg/mL suspension
DS Mupirocin 0.03% Nasal Irrigation solution 1000mL
DS Mupirocin 0.2% Nasal Spray 25mL
DS Nifedipine 0.2% & Lidocaine HCL 1.5% Topical Gel
DS Nifedipine 0.2% Gel
DS Nimodipine 30mg/mL Suspension
DS Nipple Ointment 30gm
DS Nitroglycerin 0.2% Ointment 30gm
DS Oxytocin 10units/mL Nasal Spray 5mL
DS Patch Test in White Petrolatum
DS Phytonadione 1mg/mL Oral Liquid 240mL
DS Pyrazinamide 100mg/mL suspension
DS Pyrazinamide 10mg/mL suspension
DS Ribavirin 40mg/mL Suspension
DS Rifampin 25mg/mL Suspension
DS Rifampin 50mg/mL Suspension
DS Sodium Benzoate 250mg/mL oral solution
DS Sodium Chloride 2.5mEq/mL solution 250mL
DS Squaric Acid Dibutylester in Acetone 0.5% 10mL
DS Squaric Acid Dibutylester in Acetone 2% 10mL
DS Sucralfate Enema 100mg/mL
DS Sulfacetamide 15% in 50% Ethanol Topical Solution
DS Sulfasalazine 100mg/mL Suspension
DS Tacrolimus 1mg/mL Suspension 240mL
DS Thymol 3% in 70% Ethanol 30mL
DS Toluidine Blue 1% Solution 30mL
DS Tretinoin 10mg/mL in Soybean Oil (Oleaginous oral Susp) 100mL
DS Trichloroacetic Acid 85% Solution 10mL
DS Ursodiol 25mg/mL Suspension 480mL
DS Ursodiol 25mg/mL Suspension W/TABLETS 480mL
DS Zinc Acetate 10mg/mL (Elemental Zinc) Syrup 100mL
Pick from Dropdown
Medication Not Listed
Medication 2
Freetext (Drug Name, Strength, Formulation)
Medication Size
Qty Needed
If 10 suppositories needed, write "10."
Item 3
Medication 3
Please Select
DS 123 Paste Topical 30gm
DS Acetazolamide 25mg/mL suspension
DS Acetic Acid 1% Solution 480mL
DS Acetic Acid 10% Solution 480mL
DS Acetic Acid 3% Solution 480mL
DS Acetic Acid 4% Solution 480mL
DS Acetylcholine 10% Topical Solution 10mL
DS Amiodarone 5mg/mL Suspension 400mL
DS Amphotericin B 100mg/mL oral suspension 300mL
DS Aspirin 300mg suppository
DS Azathioprine 5mg/mL suspension
DS B.I.P Ointment 85gm
DS Baclofen 5mg/mL Suspension
DS Beclomethasone (BDP) 1mg/mL in Corn Oil 500mL
DS Bevacizumab 3.75mg/0.15mL Syringe
DS Boric Acid 600mg Topical Capsule
DS Boric Acid-Polymyxin B Ear Powder 200mg
DS Boric Alcohol Ear Drops
DS Brilliant Green 5% Topical Solution 30mL
DS Budesonide 1mg/mL Suspension
DS Busulfan 10mg Capsules
DS Butyrate Enema 1000mL
DS Clobetasol Propionate 0.05% Oral Rinse Solution
DS Clonidine HCL 0.01mg/mL NICU Suspension
DS Cyclophosphamide 10mg/mL suspension
DS Cyclosporine 2% OPHTHALMIC solution 5mL
DS dexAMETHasone 1mg/mL suspension 100mL
DS Dexamethasone 24mg/mL OTIC inj 3mL
DS Diltiazem 2% in Zinc Oxide 30gm
DS EDTA Disodium 2% OPHTHALMIC solution 15mL
DS Estrogen, Conjugated Nasal Spray 0.67mg/mL 30mL
DS Flucytosine 50mg/mL Suspension 480mL
DS Formula #2 mouthwash (Aminocaporate 5% base solution) 80mL
DS Glycerin 50% Oral Solution 240mL
DS hydroCHLOROthiazide 5mg/mL suspension 100mL
DS Hydrocortisone 1% / Nystatin 0.5% in Zinc Oxide
DS Hydrocortisone 2mg/mL Suspension
DS Hydrocortisone Vaginal Suppository 100mg in Pegblend 12's
DS Hydroxychloroquine Sulfate 25mg/mL suspension
DS Hydroxyurea 100mg/mL Suspension
DS Indigo Carmine Powder 100mg (Non-Sterile)
DS Iodine Tincture 1% 240mL
DS Isradipine 1mg/mL Suspension
DS Ketamine 4mg/mL suspension
DS LCD 5% in Aquaphor
DS LCD 20% in Ethyl Alcohol Absolute
DS Lidocaine 4% Nasal Spray 25mL
DS Lisinopril 1mg/mL Suspension
DS Magic Numbing Gel 1.5mL Syringe
DS Methoxsalen 0.3% in Alcohol and Propylene Glycol 30mL
DS Metoprolol 10mg/mL Suspension 480mL
DS Morphine Sulfate Oral Solution 400mcg/mL (NICU) 100mL
DS Moxifloxacin 20mg/mL suspension
DS Mupirocin 0.03% Nasal Irrigation solution 1000mL
DS Mupirocin 0.2% Nasal Spray 25mL
DS Nifedipine 0.2% & Lidocaine HCL 1.5% Topical Gel
DS Nifedipine 0.2% Gel
DS Nimodipine 30mg/mL Suspension
DS Nipple Ointment 30gm
DS Nitroglycerin 0.2% Ointment 30gm
DS Oxytocin 10units/mL Nasal Spray 5mL
DS Patch Test in White Petrolatum
DS Phytonadione 1mg/mL Oral Liquid 240mL
DS Pyrazinamide 100mg/mL suspension
DS Pyrazinamide 10mg/mL suspension
DS Ribavirin 40mg/mL Suspension
DS Rifampin 25mg/mL Suspension
DS Rifampin 50mg/mL Suspension
DS Sodium Benzoate 250mg/mL oral solution
DS Sodium Chloride 2.5mEq/mL solution 250mL
DS Squaric Acid Dibutylester in Acetone 0.5% 10mL
DS Squaric Acid Dibutylester in Acetone 2% 10mL
DS Sucralfate Enema 100mg/mL
DS Sulfacetamide 15% in 50% Ethanol Topical Solution
DS Sulfasalazine 100mg/mL Suspension
DS Tacrolimus 1mg/mL Suspension 240mL
DS Thymol 3% in 70% Ethanol 30mL
DS Toluidine Blue 1% Solution 30mL
DS Tretinoin 10mg/mL in Soybean Oil (Oleaginous oral Susp) 100mL
DS Trichloroacetic Acid 85% Solution 10mL
DS Ursodiol 25mg/mL Suspension 480mL
DS Ursodiol 25mg/mL Suspension W/TABLETS 480mL
DS Zinc Acetate 10mg/mL (Elemental Zinc) Syrup 100mL
Pick from Dropdown
Medication Not Listed
Medication 3
Freetext (Drug Name, Strength, Formulation)
Medication Size
Qty Needed
If 10 suppositories needed, write "10."
Patient Information/ Comments
Date Needed
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