Tri-‐Mix Standard Tri-‐Mix Super Tri-‐Mix Quad Tri-‐Mix Quad Custom Papaverine 75 mg/ml Papaverine 30 mg/ml Papaverine 12 mg/ml Papaverine mg/ml Phentolamine 2.5 mg/ml Phentolamine 1.5 mg/ml Phentolamine 1 mg/ml Phentolamine mg/ml PGE-‐1 25 mcg/ml PGE-‐1 50 mcg/ml PGE-‐1 10 mcg/ml PGE-‐1 mcg/ml 5ml 10 5ml 10ml Atropine 0.15mg/ml Atropine mg/ml 5ml 10 5ml 10ml Tri-‐Mix Custom Tri-‐Mix Super Quad Custom PGE-‐1 in Normal Saline Papaverine mg/ml Papaverine 30 mg/ml Papaverine mg/ml 10 mcg / ml 10ml Phentolamine mg/ml Phentolamine 2 mg/ml Phentolamine mg/ml 20 mcg / ml 10 ml PGE-‐1 mcg/ml PGE-‐1 20 mcg/ml PGE-‐1 mcg/ml 25 mcg/ml 10ml 5ml 10 5ml 10ml Atropine mg/ml mcg/ml 10ml 5ml 10ml Bi-‐Mix 10ml Bi-‐Mix 10ml Bi-‐Mix Custom Papaverine 30 mg/ml Papaverine 30 mg/ml Papaverine mg/ml Phentolamine 1 mg/ml Phentolamine 0.5 mg/ml Phentolamine mg/ml DIRECTIONS: Start at 0.1 cc Inject Refills: . EDOX® Tablet EDOX® Tablet EDOX® Tablet 1 Month Supply 2 Month Supply 3 Month Supply 60 Tablets 120 Tablets 180 Tablets 1 tablet twice daily 1 tablet twice daily 1 tablet twice daily
931 Lexington Avenue New York N.Y 10065 Phone: 917-‐386-‐6833 Fax: 212-‐794-‐7230
ATTN: Compounding Department
Physcian: DEA #: NPI: LIC#: . Address: Telephone: Fax: .
Date: Patient: DOB: Telephone: (H) (W) (CELL) Address: City: State: Zip: Allergies/Notes:
Physician Signature:
SHIPPING & HANDLING Fed-‐Ex 3 Business Days Fed-‐Ex 2ND Business Days Fed-‐Ex Stander Overnight Fed-‐Ex Priority Overnight Fed-‐Ex Saturday
$7.00 $12.00 $18.00 $25.00 $35.00
Pricing subject to change.
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