Topical Pain Template
Prescription Template
400 Taché Ave, Winnipeg, MB R2H 2A4
Phone: (204) 233-3469 Fax: (204) 231-1739
Patient
SexMF
Base
Base
Lipoderm
PLO
Versabase
Other
+ DMSO
5%
10%
20%
Ingredient Options
Check ingredient(s) and strength
Ketamine
5%10%15% (requires duplicate Rx)%
Magnesium Chloride
10%15%%
Morphine
0.1%0.5%1%2% (requires duplicate Rx)%
Loperamide
5%10%%
Gabapentin
4%6%8%10%%
Lidocaine
2%4%5%%
Tetracaine
2%4%5%%
Bupivacaine
0.5%1%2%%
Diclofenac
2%4%5%8%10%12%%
Ketoprofen
5%10%20%%
Ketorolac
8%10%%
Cetyl Myristoleate
2%4%6%10%%
Baclofen
2%5%%
Cyclobenzaprine
2%4%5%%
Amitriptyline
2%5%%
Clonidine
0.1%0.2%%
Nifedipine
2%5%10%%
Pentoxifylline
5%10%15%%
Sildenafil
2%4%%
Guaifenesin
5%10%Menthol0.5%2%Camphor0.25%
Capsaicin
0.025%0.05%0.075%%
Additional ingredients
% %
Directions
Apply mL to affected area(s): Frequency:
Quantity
grams
(Total % ≤ 30%)
Refills
Prescriber
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Signature