Physician Inbound Request
Formulation request from providers.
What product(s) are they requesting?
What type of dosage form are they requesting?
What is the desired concentration?
Will this be used for an office administration?
What is the provider treating?
How many patients do they expect to use this formulation per month?
One time only
Is the medication commercially available?
Why do they want it compounded? (ex. Too Expensive, Dosage form, Not Available Commercially etc.)
What ingredients would they like the formulation to contain/not contain (active and/or inactive, specific bases)?
Should be Empty: