Topical Peyronie’s Template
Prescription Template
400 Taché Ave, Winnipeg, MB R2H 2A4
Phone: (204) 233-3469 Fax: (204) 231-1739
Patient
SexMF
Topical Treatment
Check ingredient(s) and strength
Verapamil
15%
%
Other
%
Vanpen base unless otherwise specified.
Other base
Quantity
60 gm
or
gm
Refills
1 year
or
Directions
Apply 0.5 mL twice daily. If pain persists after 3
months, increase to 1 mL twice daily.
Prescriber
|
|
|
|
|
|
Signature