Topical Scar & Stretch Marks Template

Prescription Template

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

Patient

Name

DOBSexMF

PHIN

Phone

Date

Scar / Stretch Marks Treatment

Check formula

Tretinoin 0.1% in Pracasil-Plus

Add: Aloe Vera 0.5%

Collagenase 350 U/g, hyaluronidase 250 U/g in Pracasil-Plus

Check formula

Topiramate 2.5% Pracasil-Plus

Add: Betamethasone 0.1% 0.5%

Topiramate 2.5%, Caffeine 1%, Tranilast 1%, Pentoxifylline 1% in Pracasil-Plus

Fluocinolone acetonide 0.01%, Hydroquinone 4%, Tretinoin 0.05% in Pracasil-Plus

Quantity grams

Refills

Directions Apply twice daily to affected area(s) — specify:

Name	Clinic
Phone	Fax

Signature