All-Purpose Nipple Cream Template
Prescription Template
400 Taché Ave, Winnipeg, MB R2H 2A4
Phone: (204) 233-3469 Fax: (204) 231-1739
Patient
SexMF
Common Formulations
Check formula
Formula #1: Ointment or Cream
- Miconazole 2%
- Mupirocin (Bactroban) 1%
- Betamethasone 0.05%
Formula #4: Ointment or Cream
- Nystatin 128,000 U/gram
- Mupirocin (Bactroban) 1%
- Betamethasone 0.05%
Formula #2: Ointment or Cream
- Miconazole 2%
- Mupirocin (Bactroban) 1%
- Betamethasone 0.05%
- Ibuprofen 2%
Formula #5: Ointment or Cream
- Clotrimazole 2%
- Mupirocin (Bactroban) 1%
- Betamethasone 0.025%
Formula #3: Ointment or Cream
- Clotrimazole 0.25%
- Nystatin 25,000 U/gram
- Mupirocin (Bactroban) 0.5%
- Betamethasone 0.025%
Formula #6: Ointment or Cream
- Miconazole 2%
- Nystatin 25,000 U/gram
Formula #7: Ointment
- Vitamin E Acetate 0.5%
- Olive Oil 5%
Ointment will provide more occlusion and likely allow faster healing.
Base
Ointment
Cream
Refills
1
2
3
4
5
6
NR
Quantity
grams
Directions
Apply after each feeding
or
HS
QD
BID
TID
QID
Other
Prescriber
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Signature