Physician Inbound Request
Formulation request from providers.
Office Name
Name
First Name
Last Name
Email
example@example.com
Phone Number
-
Area Code
Phone Number
What is your preferred method of contact?
Call
Text
Email
What product(s) are they requesting?
What type of dosage form are they requesting?
Topical Cream/Gel
Sterile Injection
IV Product
Oral Suspension
Capsules
Troches
Ophthalmic Drop
Suppository
Nasal Spray
Inhalation Solution
Otic Drop
Vaginal Cream/Gel
Rectal Cream/Gel
Other
What is the desired concentration?
Suggested Sig./Protocol
Will this be used for an office administration?
Yes
No
Unsure
What is the provider treating?
How many patients do they expect to use this formulation per month?
One time only
1-10
11-50
51+
Is the medication commercially available?
Yes
No
Unsure
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)?
Additional Comments
Submit
Should be Empty: