Scopolamine Topical Gel Template

Prescription Template

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

Patient

Name

DOBSexMF

PHIN

Phone

Date

Preparation

Scopolamine 0.25 mg per 0.1 mL in permeation-enhanced topical gel

Dispensed in pre-marked oral syringes for measured topical dosing. Commonly used in palliative care plans for respiratory secretions and hypersalivation when a non-oral route is needed.

Directions

Apply mL ( mg) topically to the inner wrist every hours (PRN / scheduled)

0.1 mL = 0.25 mg. Rotate between wrists; caregivers should apply with a gloved finger or wash hands immediately after.

Indication

Quantity mL Refills

Notes for the Care Team

Caregiver instruction sheet requested with dispense (tachepharmacy.com/instructions/scopolamine-gel)

Deliver to patient / facility — address with patient information above

Pharmacist to call prescriber on receipt

Prescriber

Name	Clinic
Phone	Fax

Signature