Boothwynpharmacy.com

Pain Therapy
Fax: 888-985-9223
Referral Form
Fax: 610-485-9223
Patient Information
Patient Name: ___________________ Date of Birth: ___ ___ ______ Sex: ☐ Male ☐ Female Height:_____ Weight:_____ lbs SSN #: ______-_____-_______ Mobile Phone: (_____)_____ _____ Known Allergies:_____________________________________ Address: __________________________________________________ City: __________________ State:________ Zip: __________ Alternate Caregiver Name: ___________________________________ Preferred Phone: (_____)____ _____
Diagnosis | Clinical Information
Diagnosis: ___________________________________________________________________________ ICD-9 Code: ____________ ____________________________________________________________________________ Anti-Inflammatory Creams
☐ Cascade Diclofenac 3% Baclofen 2% (CDB) Cream☐ Cascade Diclofenac 3% Baclofen 2% Cyclobenz. 2% Tetracaine 2% (BCDT) Cream Neuropathic Pain Creams
☐ Ketamine 10% Baclofen 2% -Cyclobenzaprine 2% - Gabapentin 6% - Lidocaine 5% (KBCGL) Cream☐ Ketamine 10% - Clonidine 0.2% - Gabapentin 6% - Imipramine 3% - Mefenamic Acid 3% - Tetracaine 2% (KCBIMT) Cream ☐ Ketamine 10% - Baclofen 2% - Gabapentin 6% -Imipramine 3% -Nifedipine 2% -Tetracaine 2% (KBGINT) Cream Combination Pain Creams
☐ Diclofenac 3% - Baclofen 2% - Cyclobenzaprine 2% - Gabapentin 6% - Tetracaine 2% (DBCGT) Cream☐ Ketamine 10% - Baclofen 2% - Cyclobenzaprine 2% - Diclofenac 3% - Gabapentin 6% - Tetracaine 2% (KBCDGT) Cream QTY:____________90 GM__________120 GM_____________180 GM_____________240 GM____________Alternate SIG: ______________________________________________________________________________ *NOTE: Please cross out any unwanted medication in the above formulations.
**NOTE: Ketamine is controlled schedule III. Substitute Amantadine 8% if desired.
Additional Prescription Options
☐ Comments or additional prescriptions:_____________________________________________________________________________ SIG:_________________________________________________________ N 1 2 3 4 5 refills Physician Information
Physician Name: (printed) _______________________________________ Date: _____ _____ ________ Physician Signature: ____________________________________________ DEA#: __________________ NPI#: ________________ Person Faxing Form (printed): ____________________________________ Phone: (_____)____ _____ Fax: (_____)____ _____ Address: ________________________________________________ City: _________________________ State:_____ Zip: ________ **First Order: Please FAX Patient Demographics
SHIP TO: (circle one) Physician Patient
i.e. current insurance and address information **
Four ways to place prescription: Tel: 800-485-1130 | Fax: 888-985-9223 | Email: Refill@bpi-rx.com | Online: BoothwynPharmacy.com
DISCLAIMER: This prescription may be filled at any pharmacy. Include current medications & allergy list. Suggested preparations are based on previous prescriptions, other strengths & sizes may be available.
LEGAL NOTICE: This FAX may contain confidential information belonging to the sender which is legally protected. This information is intended solely for the use of the individual named above.
If you are not the intended recipient, you are hereby advised that any dissemination, distribution or copying of this communication is prohibited. If you received this fax in error, please immediately notify the sender by telephone to arrange for the return of the original document.

Source: http://boothwynpharmacy.com/forms/BPI-PainTherapyReferral.pdf