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Physician:_______________________________ City____________________ State____ Zip_______ Okatie, SC 29936 Phone_________________ Fax________________ Phone: (888)-322-6641
FAX: (843)-645-9987
Patient Name: ______________________________ Date: ___________________
Address: ___________________________________ City: ____________________ State: _______ Zip Code: _______
Date of Birth: _______________________________ Allergies: ________________
Telephone Number: _________________________
Nausea/Vomiting/Agitation
 Lorazepam 1 mg/mL/Diphenhydramine 12.5 mg/mL/Haloperidol  Ondansetron 4 mg/0.1 mL Topical Lipoderm Ginger Root 200 mg capsules  ABHR (Lorazepam/Diphenhydramine/Haldol/Metoclopromide) Lorazepam gel (1mg/ml) Sig: _____________________________________________________________________________________ Quantity: _________ ________________________________________________________________________________________________________________________________
Dry Mouth
 Sodium Cl 8.8 mg/Potassium Cl 3.1 mg/Calcium Cl 3.4 mg Base A Troche Sig: ________________________________________________________________________________________ ________________________________________________________________________________________________________________________________
Mouth Pain
 Misoprostol 0.0024%/Diphengydramine HCl 0.1%/Compound Oral Rinse  Morphine Sulfate 1 mg/mL Oral Gel Diphenhydramine HCl 25 mg/Lidocaine HCl 2%/Hydrocortisone 1%  Magic Mouthwash (Tetracycline/Diphenhydramine/Lidocaine/Maalox)* *( You can customize your own mouthwash) Sig: _____________________________________________________________________________________ Quantity: _________ ________________________________________________________________________________________________________________________________
Pain Managment
 Ketoprofen 10% Topical Lipoderm
 Ketamine 10%/Gabapentin 6%/Clonidine 0.2%/Nifedipine 2% Topical Lipoderm  Diclofenac Sodium 10% Lipoderm Transdermal Gel  Ketamine 10%/Gabapentin 6%/Clonidine 0.2%/Nifedipine 2% Topical Lipoderm* *(Ideal for Neuropathic pain) Sig: _____________________________________________________________________________________ Quantity: _________ ________________________________________________________________________________________________________________________________
Wound Care Managment
 Phenytoin 5%/Misoprostol 0.0024% Topical Gel
 Phenytoin 2%/Misoprostol 0.0024%/Lidocaine 2%/Bupivacaine 0.2%/Diphenhydramine  Ketoprofen 2%/Lidocaine 2%/Misoprostol 0.0024%/Phenytoin 2%/Aloe Vera 0.2%  Misoprostol 0.0024%/Phenytoin 5%/Metronidazole 2% Topical Gel Sig: _____________________________________________________________________________________ Quantity: _________ ________________________________________________________________________________________________________________________________
Physician Signature: ____________________________

Source: http://www.lowcountryrx.com/wp-content/uploads/2010/10/NauseaPainWound.pdf