Mouthrinse Template
Prescription Template
400 Taché Ave, Winnipeg, MB R2H 2A4
Phone: (204) 233-3469 Fax: (204) 231-1739
Patient
SexMF
Popular Combinations
Check one
Magic Mouthwash — diphenhydramine 0.075%, hydrocortisone 0.125%, nystatin 7,500 u/mL, lidocaine 0.4%
Super Magic Mouthwash — diphenhydramine 0.125%, dexamethasone 0.00033%, tetracycline 1.25%, lidocaine 1%
Tetracaine 0.5%, hydrocortisone 1%, clotrimazole 2%, sucralfate 15.6%
Ketamine 0.03%, tetracaine 0.5%, sucralfate 15.6% (requires duplicate Rx)
Pink Lady — Xylocaine Viscous 2% : Maalox, 1:1
Modified Pink Lady — Xylocaine Viscous 2% : Maalox : Benadryl Elixir, 1:1:1
Or Build a Custom Rinse
Check ingredient(s) and strength
Ketamine
0.03%0.4% (requires duplicate Rx)%
Morphine
0.2%0.5% (requires duplicate Rx)%
Gabapentin
6%%
Lidocaine
0.4%1%2%%
Tetracaine
0.5%1%%
Diphenhydramine
0.075%0.125%0.2%%
Hydrocortisone
0.125%0.5%1%%
Dexamethasone
0.00033%%
Sucralfate
4%8%15.6%%
Clotrimazole
2%%
Nystatin
7,500 u/mLu/mL
Tetracycline
1.25%%
Misoprostol
0.0024%%
Additional ingredients
% %
Directions
Swish & spit
10–15 mL or mL q 2–3 hours or (frequency) as needed.
or
Swish & swallow
mL (frequency) as needed.
Consider systemic effects when determining volume and frequency if swallowing.
Mucolox base — swish and spit 5 mL BID to QID as needed, or swish and swallow 5–10 mL BID to QID as needed.
Quantity
mL
Refills
Prescriber
|
|
|
|
|
|
Signature