SOUTHERN MARYLAND COMPOUNDING CENTER PHARMACY

Patient Name

DOB

TO EXPEDITE ORDER, PLEASE INCLUDE FRONT AND BACK OF INSURANCE CARD AND PATIENT DEMOGRAPHIC SHEET

Phone

Address

PEDIATRICS

Eczema Hydrocortisone Acetate 0.2% Topical Cream

Cyanocobalamin 0.07% Topical Cream

Cyanocobalamin 0.1% Topical Foam

Chicken Pox PCCA Formula # 1986 Oatmeal/Allentown Lotion

PCCA Formula # 3140 Oatmeal/Calamine/Pramoxine Hydrochloride Lotion

Diphenhydramine HCl 1%/Calamine 8% Topical Cream

Diphenhydramine HCl 2%/Hydrocortisone 0.5% Topical Cream

Lidocaine HCl 1%/Tetracaine HCl 1% Topical Foam

Topical Anesthetics

All of these drugs have a quick onset of action. Lidocaine HCl 4%/Tetracaine HCl 0.5%/Epinephrine HCl 0.05%

Lidocaine HCl 1%/Tetracaine HCl 1% Topical Foam

Topical Gel

Nausea & Vomiting Ondansetron 4 mg/0.1 mL Topical Lipoderm

Ginger Root 200 mg Sorbitol Lollipop Base

Promethazine HCl 50 mg/mL Topical LipodermR (Stabilized)

Promethazine HCl 25 mg/mL Topical LipodermR

Custom Recipe:

QTY:

240(g or ml) 120(g or ml)

90(g or ml) 60(g or ml)

30(g or ml)

ALTERNATE QTY: ___________

SIG: ________________________________________________________________________ REFILLS:

0

1

2

3

4

5

PRN

DAW________

Physician Name: (Please Print) __________________________________Phone:____________________ Fax: _______________________________DEA:_______________________________ Physician Signature: _________________________________________Date:___________________

3643 LEONARDTOWN ROAD, WALDORF, MD 20601 PHONE (301) 645-2400 FAX (301) 476-0382

SOUTHERN MARYLAND COMPOUNDING CENTER PHARMACY

Patient Name

DOB

Phone

TO EXPEDITE ORDER, PLEASE INCLUDE FRONT AND BACK OF INSURANCE CARD AND PATIENT DEMOGRAPHIC SHEET

Address

PEDIATRICS

Please check the box that applies Acne Niacinamide 3%/Lipoic Acid 0.5% Topical Cream

Niacinamide 4% Acne Gel

Niacinamide 4%/Biotin 0.1%/Lipoic Acid 0.5% Topical Acne Gel, Alternate

Body Odor/Excessive Sweating/Hyperhidrosis PCCA Formula # 3800 NonMetallic Deodorant

Methenamine 5%/Benzalkonium Chloride 2%/Chlorhexidine Digluconate 0.5% Topical Spray

Tree Oil 2.5%/Tannic Acid 5% Deodorant & Antiperspirant Stick

Glycopyrrolate 0.5% Topical Solution

Glutathione 20%/Emu Oil 10% Topical Anhydrous LipodermR

Methylcellulose 1% Flavored Suspension Vehicle (PF)

Autism DMPS 20% Topical Anhydrous LipodermR

DMSA 20%/Emu Oil 10% Topical Anhydrous LipodermR

(This is sometimes referred to as the Autism Suspending Vehicle. It is often used for autistic patients)

Custom Recipe:

QTY:

240(g or ml) 120(g or ml)

90(g or ml) 60(g or ml)

30(g or ml)

ALTERNATE QTY: ___________

SIG: ________________________________________________________________________ REFILLS:

0

1

2

3

4

5

PRN

DAW________

Physician Name: (Please Print) ____________________________________Phone:________________________ Fax: _______________________________DEA:_______________________________ Physician Signature: _________________________________________Date:___________________

3643 LEONARDTOWN ROAD, WALDORF, MD 20601 PHONE (301) 645-2400 FAX (301) 476-0382

SOUTHERN MARYLAND COMPOUNDING CENTER PHARMACY

Patient Name

DOB

Phone

TO EXPEDITE ORDER, PLEASE INCLUDE FRONT AND BACK OF INSURANCE CARD AND PATIENT DEMOGRAPHIC SHEET

Address

PEDIATRICS

Commonly Prescribed Suspensions Omeprazole 2 mg/mL Oral Suspension

Lansoprazole 3 mg/mL Oral Suspension

Sildenafil Citrate 1 mg/mL Oral Suspension

Ranitidine 150 mg/5 mL Oral Suspension

Atomoxetine 6 mg/mL Oil Oral Suspension

Acetazolamide 25mg/mL Oral Suspension

Aldactazide 5mg/mL Oral Suspension

Allopurinol 20 mg/mL Oral Suspension

Amlodipine 1 mg/mL Oral Suspension

Azathioprine 50 mg/mL Oral Suspension

Baclofen 5mg/mL Oral Suspension

Calcium Carbonate 200mg/mL Oral Suspension

Carvedilol 1.67mg/mL Oral Suspension

Chloroquine Phosphate 15 mg/mL

Chocolate SyrupSUSPENDING AGENT

Custom Recipe:

QTY:

240ml 120r ml

90ml 60 ml

3ml

ALTERNATE QTY: ___________

SIG: ________________________________________________________________________ REFILLS:

0

1

2

3

4

5

PRN

DAW________

Physician Name: (Please Print) ____________________________________Phone:________________________ Fax: _______________________________DEA:_______________________________ Physician Signature: _________________________________________Date:___________________

3643 LEONARDTOWN ROAD, WALDORF, MD 20601 PHONE (301) 645-2400 FAX (301) 476-0382

SOUTHERN MARYLAND COMPOUNDING CENTER PHARMACY

Patient Name

DOB

Phone

TO EXPEDITE ORDER, PLEASE INCLUDE FRONT AND BACK OF INSURANCE CARD AND PATIENT DEMOGRAPHIC SHEET

Address

PEDIATRICS

Commonly Prescribed Suspensions Please check the box that applies Tacrolimus 0.5mg/mL Oral Suspension

Terbinafine 25mg/mL Oral Suspension

Trimethoprim 10 mg/mL Oral Suspension

Ursodiol 50mg/mL Oral Suspension

Valganciclovir 60mg/mL Oral Suspension

Zinc Sulphate 10mg Zn++/mL Oral Solution

Custom Recipe:

QTY:

240ml 120 ml

90ml 60 ml

3ml

ALTERNATE QTY: ___________

ALTERNATE QTY: ___________ SIG: ________________________________________________________________________ REFILLS:

0

1

2

3

4

5

PRN

DAW________

Physician Name: (Please Print) ____________________________________Phone:________________________ Fax: _______________________________DEA:_______________________________ Physician Signature: _________________________________________Date:___________________

3643 LEONARDTOWN ROAD, WALDORF, MD 20601 PHONE (301) 645-2400 FAX (301) 476-0382

SOUTHERN MARYLAND COMPOUNDING CENTER PHARMACY

TO EXPEDITE ORDER, PLEASE Patient Name__________________________________________________Phone_________________________________________________ INCLUDE FRONT AND BACK OF DOB INSURANCE CARD AND PATIENT Address_____________________________________ DEMOGRAPHIC SHEET

Physician Name: (Please Print) __________________________________________Date___________

DAW___ ___ Physician Signature: _________________________________________Date:_____________ DAW________ Please check the box that applies Physician Signature_______________________________DEA:__________________Tel_____________

Commonly Prescribed Suspensions Citric Acid 25% Solution

Clonazepam 0.1mg/mL Oral Suspension

Clonidine 0.1mg/mL Oral Suspension

Dantrolene

Dapsone 2mg/mL Oral Suspension

Dexamethasone Phosphate 1 mg/mL Oral Syrup

Dipyridamole 10mg/mL Oral Suspension

Enalapril 1mg per mL

Flecainide Acetate 20mg/mL Suspension

Gabapentin 100mg/mL Suspension

Hydrocortisone 1 mg/mL Oral Suspension

Hydralazine HCI 1mg/mL Oral Solution

Hydrochlorothiazide 5mg/mL Oral Sups.

Indomethacin 5 mg/mL Oral Suspension

Ketoconazole 20mg/mL Oral Suspension

Levodopa 5mg/mL/Carbidopa 1.25mg/mL Oral Suspension

Losartan 2.5mg/mL Oral Suspension

1% Methylcellulose SickKids

Metoprolol 10mg/mL Oral Suspension

Metronidazole 15 mg/mL Oral Suspension

Mexiletine 10mg/mL Oral Suspension

Midazolam HCl 3 mg/mL Oral Syrup

SickKids Mouthwash for Pain

Nadolol 10 mg/mL Oral Suspension

Nitrazepam 1 mg/mL Oral Suspension

Nitrofurantoin 10mg/ML Oral Suspension

Omeprazole 2mg/mL Oral Suspension

Oseltamivir 15 mg/mL Oral Suspension

Prednisone 5 mg/mL Oral Suspension

Preserved Water with Sodium Benzoate

Propranolol HCl 1 mg/mL Oral Suspension

Pyrazinamide 100mg/mL Oral Suspension

Pyrimethamine 2mg/mL Suspension

Riboflavin 10mg/mL Oral Suspension

Rifampin 25 mg/mL Oral Suspension

Sodium Bicarbonate 8.4%

Sotalol HCl 5 mg/mL Oral Suspension

Spironolactone 5mg/mL Oral Suspension

Sucrose 24% W V Oral Solution

Sulfasalazine 100mg/mL Oral Suspension

QTY:

240ml 120r ml

90ml 60 ml

3ml

ALTERNATE QTY: ___________

SIG: ________________________________________________________________________ REFILLS:

0

1

2

3

4

5

PRN

3643 LEONARDTOWN ROAD, WALDORF, MD 20601 PHONE (301) 645-2400 FAX (301) 476-0382

SOUTHERN MARYLAND COMPOUNDING CENTER PHARMACY

TO EXPEDITE ORDER, PLEASE INCLUDE FRONT AND BACK OF INSURANCE CARD AND PATIENT DEMOGRAPHIC SHEET

Patient Name

DOB

Phone

Address

PEDIATRICS

Please check the box that applies Diaper Rash Nystatin 0.758%/Karaya Gum 33% Topical Ointment

Cholestyramine 5% Diaper Rash Ointment

Happy Hiney

Buttocks Ointment

Cough/Cold

Zinc Oxide 5%/Benzoin Compound Topical Paste

Ear Infections

Menthol 0.1%/Eucalyptus 0.275% Sorbitol Lollipop Base

Oral xylitol is often requested for patients with chronic ear infections. Xylitol 2 Gm Sorbitol lollipop Base

Fever Ibuprofen 100 mg Sorbitol lollipop Base

Acetaminophen 240 mg Sorbitol lollipop Base

Lice

Ibuprofen 10% in Lipoderm Transdermal Gel

Colic

Ivermectin 1% Topical Lotion

Formula # 2388 Gripe Water

Psoriasis Vitamin B12 is used in various diseases of the skin.

Vitamin B12 is used in various diseases of the skin.

Cyanocobalamin 0.07% Topical Cream

Cyanocobalamin 0.1% Topical Foam

Custom Recipe:

QTY:

240(g or ml) 120(g or ml)

90(g or ml) 60(g or ml)

30(g or ml)

ALTERNATE QTY: ___________

SIG: ________________________________________________________________________ REFILLS:

0

1

2

3

4

5

PRN

DAW________

Physician Name: (Please Print) ____________________________________Phone:________________________ Fax: _______________________________DEA:_______________________________ Physician Signature: _________________________________________Date:___________________

3643 LEONARDTOWN ROAD, WALDORF, MD 20601 PHONE (301) 645-2400 FAX (301) 476-0382