ED Injection Template
Prescription Template
400 Taché Ave, Winnipeg, MB R2H 2A4
Phone: (204) 233-3469 Fax: (204) 231-1739
Patient
SexMF
Injectable Preparations
Check one preparation
Bimix
Papaverine 30 mg
Phentolamine 1 mg
per mL
M: 10 mL (2 × 5 mL)
Trimix
Alprostadil 5.9 mcg
Papaverine 17.6 mg
Phentolamine 0.65 mg
per mL
M: 5 mL (2 × 2.5 mL vials)
Quadmix
Alprostadil 10 mcg
Papaverine 12 mg
Phentolamine 1 mg
Atropine 0.15 mg
per mL
M: 5 mL (2 × 2.5 mL vials)
Relative potency — Bimix 4 : Trimix 2 : Quadmix 1
Refills
1
2
3
or
Directions
Use as directed
or
Supplies
Included with every preparation
Monoject 29G 1/2” 1 mL Syringe
M: 20 syringes
Sig: Use as directed
Refill: 3
BD Alcohol Swabs
M: 20
Sig: Use as directed
Refill: 3
Prescriber
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Signature