Topical Anal Fissure Template
Prescription Template
400 Taché Ave, Winnipeg, MB R2H 2A4
Phone: (204) 233-3469 Fax: (204) 231-1739
Patient
SexMF
Topical Treatment
Check ingredient(s) and strength
Nifedipine / Diltiazem
Nif 0.2%
Nif 0.3%
Nif 0.5%
or
Dilt 2%
Nitroglycerin
0.125% (maximum
strength)
Lidocaine
1%
2%
Hydrocortisone
1%
2%
Other
%
Vaseline base unless otherwise specified.
Other base
Quantity
gm
Refills
Directions
Apply to the affected area 2 to 3 times daily and after
a bowel movement
Rectal Rocket Suppository
Check ingredient(s) and strength
Misoprostol
0.0024%
Sucralfate
15.6%
Hydrocortisone
1%
2%
Lidocaine
1%
2%
Nifedipine
0.2%
0.3%
0.5%
Other
%
Directions
Instill 1 rectal rocket at bedtime for
days. Lay in a supine position.
Quantity
rectal rockets
Refills
Prescriber
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Signature