Trimix 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

Trimix Gel

Check quantity

Alprostadil 300 mcg / papaverine 6 mg / phentolamine 0.4 mg / lidocaine 10 mg
per 0.2 mL

30 day expiry date once mixed.

Quantity

1 syringe of 0.6 mL 2 syringes of 0.6 mL 3 syringes of 0.6 mL

Refills

1 2 3 or

Directions Instill 0.2 mL into the urethra as directed

Name	Clinic
Phone	Fax

Signature