Common Pain Preparations Template

Prescription Template

400 Taché Ave, Winnipeg, MB R2H 2A4
Phone: (204) 233-3469   Fax: (204) 231-1739

Patient

SexMF

Rheumatoid Arthritis / Joint Pain

Diclofenac 10%, Tetracaine 5%, DMSO 10% in Lipoderm
Ketorolac 10%, Tetracaine 5%, DMSO 10% in Lipoderm
Add
CMO 2%Baclofen 2%

Lower Back Pain

Diclofenac 8%, Baclofen 2%, Tetracaine 2%, DMSO 5% in Lipoderm
Diclofenac 8%, Baclofen 5%, Tetracaine 5%, DMSO 10% in Lipoderm
Add
CMO 2%Amitriptyline 2%

Post-Herpetic Neuralgia

Ketamine 10%, Morphine 1%, Amitriptyline 2%, Lidocaine 5% in Lipoderm (requires M3P)
Ketamine 15%, Morphine 2%, Amitriptyline 5%, Lidocaine 5% in Lipoderm (requires M3P)
Benzocaine 5%, Lidocaine 10%, Tetracaine 5% Spray

Add gabapentin 2% to make the spray eligible for Pharmacare.

Neuropathic Pain

Loperamide 10%, Gabapentin 6%, Amitriptyline 2%, DMSO 5%, Tetracaine 5% in Lipoderm
Ketamine 10%, Morphine 1%, Gabapentin 6%, Amitriptyline 2%, Tetracaine 5% in Lipoderm (requires M3P)
DirectionsApply mL to affected area(s) — area: frequency:
QuantitygramsRefills

Prescriber
Signature

Common Pain Preparations Template

Prescription Template

400 Taché Ave, Winnipeg, MB R2H 2A4
Phone: (204) 233-3469   Fax: (204) 231-1739

Patient

Base

Applies to formulas below unless noted
Lipoderm PLO Versabase Other — specify

Radiation Burns

Morphine 0.5%, Lidocaine 2%, Gabapentin 6% (requires M3P)
Ketoprofen 2%, Lidocaine 2%, Misoprostol 0.0024%, Phenytoin 2%, Aloe Vera 0.2%

Raynaud’s Syndrome

Nifedipine 4%, Pentoxifylline 10%, Sildenafil 2% in Lipoderm
Nifedipine 6%, Pentoxifylline 10%, Sildenafil 4% in Lipoderm
Nitroglycerin 0.9% in Glaxal Base

Chemo-Induced Peripheral Neuropathy

Ketamine 5%, Baclofen 5%, Lidocaine 5% in Lipoderm (requires M3P)
Add
Morphine 1% (also requires M3P)

Anal Fissures

Nifedipine 0.2%, Lidocaine 2%, Hydrocortisone 1% Ointment
Add
Sucralfate 4%
Rectal Rocket — Sucralfate 15.6%, Hydrocortisone 1%, Lidocaine 2%, Nifedipine 0.2%
DirectionsApply mL to affected area(s) — area: frequency:
QuantitygramsRefills

Prescriber
Signature