Bioidentical Hormone Preparations Template
Prescription Template
400 Taché Ave, Winnipeg, MB R2H 2A4
Phone: (204) 233-3469 Fax: (204) 231-1739
Patient
SexMF
Topical Creams & Gels
Check hormone, strength, and base
Testosterone
0.1%1%2%2.5%5%10%%
Estriol
0.05%0.1%0.2%%
Estradiol
0.01%0.1%%
Bi-est ratio (E3:E2)
80:2060:4050:50total mg/g
Progesterone
5% (50 mg/mL)6% (60 mg/mL)%
Base
VersaBase creamVersaBase gelAtrevis (scalp/transdermal)Organic cream
Progesterone Capsules
Check one
25 mg
50 mg
50 mg MR
100 mg
150 mg MR
200 mg
mg
MR = modified release. Vegetable capsules available on request.
Directions
Sig
Patient application instructions for topical estrogen are at tachepharmacy.com/instructions/applying-topical-estrogen and are dispensed with each fill on request.
Quantity
Refills
Prescriber
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Signature