Topical Urticaria & Pruritus Template

Prescription Template

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

Patient

Name

DOBSexMF

PHIN

Phone

Date

Urticaria / Pruritus — XemaTop Base

Check one formula

Doxepin 5%, Lidocaine 2% 5% (suggested: apply QID)

Naltrexone 1%, Pramoxine 1%, Tranilast 1% (suggested: apply BID)

Naltrexone 0.5%, Diphenhydramine 2%, Vitamin D3 5,000 IU/g (suggested: apply BID)

Ketamine 1% 5% 10%, Amitriptyline 2% 5%, Lidocaine 2% 5%

Requires M3P (duplicate Rx). Suggested: apply BID–TID.

Optional

Hydrocortisone

1%2%%

Betamethasone

0.05%0.1%

Camphor

0.25%0.5%

Aloe vera

0.5%1%

Ketotifen

0.05%

Apply BID TID QID or to affected area(s) — specify:

QuantitygramsRefills

Name	Clinic
Phone	Fax

Signature