Otic Drops Template

Prescription Template

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

Patient

Name

DOBSexMF

PHIN

Phone

Date

Compounded Otic Preparations

Check one

Acetic acid 2% / hydrocortisone 1% otic solution — the compounded equivalent of discontinued Vosol-HC; commonly prescribed for otitis externa

Clotrimazole 1% otic solution (sterile preparation) — commonly prescribed for otomycosis / fungal otitis externa

Acetic acid 2% otic solution (no corticosteroid)

Other:

Instill drops into the left right both ear(s), (frequency), for days

Patient should lie with the treated ear up for a few minutes after instilling. Warm the bottle in the hands first — cold drops are uncomfortable.

Quantity mL Refills

Perforated tympanic membrane considered — acetic acid preparations are generally avoided with perforation; pharmacist will confirm if unclear

Pharmacist to call prescriber on receipt

Name	Clinic
Phone	Fax

Signature