ࡱ> wyv7 0bjbjUU 7|7| 7$lllll   8L X $ kmmmmmm~ m I @ mll  l8  k kkk | seD 4kk0kJ $JkllllPatient Name: _________________________________________ Address: _________________________________________ _________________________________________ TRI-EST SR Capsules (Estriol, Estradial, Estrone) Dose: 0.5mg 1.0mg 1.5mg 2.0mg other: _____ Quantity: _______________ Sig: Take ________ cap/s orally in the AM Refill: 1 2 3 4 5 1yr TRI-EST Cream (Estriol, Estradial, Estrone) Dose: 1.25mg/ml 1.75mg/ml 2.0mg/ml 2.5mg/ml other: ____mg/ml Quantity: _______________ml Sig: Apply ________ml to intact skin ___ time/s daily Refill: 1 2 3 4 5 1yr BI-EST SR Capsules (Estradiol /Estriol,) Dose: 1.0mg/0.5mg 1.5mg/0.5mg 2.0mg/0.5mg other: ____mg/0.5mg Quantity: _______________ Sig: Take ________ cap/s orally in the AM Refill: 1 2 3 4 5 1yr Estriol Facial Cream 30gm Dose: 0.3% 0.5% Quantity: _______________ Sig: Apply ________ time/s daily Refill: 1 2 3 4 5 1yr Compounded Thyroid T3/T4 SR Dose: 15mg 30mg 60mg 90mg 120mg other: _____mg Quantity: _______________ Sig: Take ________ cap/s orally in the AM Refill: 1 2 3 4 5 1yr DHEA Dose: 25mg 50mg 100mg other: _____mg Quantity: _______________ Refill: 1 2 3 4 5 1yr Co Q10 Dose: 30mg 60mg other: _____mg Quantity: _______________  Refill: 1 2 3 4 5 1yr Date: ______________________________ Phone: _____________________________ Date of Birth: _______________________ Progesterone SR Capsules Dose: 50mg 100mg 125mg other: _____ Quantity: _______________ Sig: Take ________ cap/s orally in the PM Refill: 1 2 3 4 5 1yr Progesterone Cream Dose: 25mg/ml 50mg/ml 100mg/ml other: ____mg/ml Quantity: _______________ml Sig: Apply ________ml to intact skin ____ times daily Refill: 1 2 3 4 5 1yr Progesterone Triturate (12 per blister pack) Dose: 25mg 50mg 100mg other: _____ Quantity: _______________ Sig: Dissolve ________ under the tongue____ times daily Refill: 1 2 3 4 5 1yr Testosterone Gel (alcohol base) Dose: 50mg/ml 70mg/ml 90mg/ml other: ____mg/ml Quantity: _______________ml Sig: Apply ________ml to intact skin ___ time/s daily Refill: 1 2 3 4 5 1yr Testosterone Vanishing Cream (water soluble base) Dose: 10mg/ml 20mg/ml other: ____mg/ml Quantity: _______________ml Sig: Apply ________ml to intact skin ___ time/s daily Refill: 1 2 3 4 5 1yr Melatonin SR Dose: 1mg 2mg 3mg other: _____mg Quantity: _______________  Refill: 1 2 3 4 5 1yr American Hormones, Inc. - Order Form Prescribing Physician: _________________________________________________ DEA # ___________________________________ Signature Please PRINT Physicians Name & Address: _________________________________________________ Phone: ____________________________________ _________________________________________________ Fax signed script to 866-597-7601 8 t   -/0>*CJ 5CJ\j5CJU\mHnHu5\jUmHnHu 5CJH*\ 5CJ\89uv(Cn *aAlm ! /b} & Q X   : ; T  ! 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