Endocrinology

Phone: (877) 868-4110 Fax: (877) 868-4144

FREE DELIVERY

2743 W. 15th St., Plano, TX 75075 Ph: 877-868-4110 Fax: 877-868-4144 INTRATHECAL MEDICATION LIST BACLOFEN

Strengths up to 1000mcg/ml 1001mcg/nl up to 2000mcg/ml 2001mcg/ml up to 4000mcg/ml

Up to 20cc

21 to 30cc

31 to 60cc

BUPIVACAINE

Strengths up to 8mg/ml (.8%) 8.1mg/ml up to 40mgml (4%)

Up to 20cc

21 to 30cc

31 to 60cc

CLONIDINE

Strengths up to 2000mcg/ml 2001mcg/ml to 4000mcg/ml

Up to 20cc

21 to 30cc

31 to 60cc

DROPERIDOL

Strengths up to 20mcg/ml 21mcg/ml and up

Up to 20cc

21 to 30cc

31 to 60cc

FENTANYL

Strengths up to 50mcg/ml 51mcg/ml up to 500mcg/ml 501mcg/ml up to 1000mcg/ml 1001mcg/ml up to 3000mcg/ml 3001mcg/ml up to 5000mcg/ml 5001mcg/ml up to 7500mcg/ml 7501mcg/ml up to 10,000mcg/ml 10,001mcg/ml up to 15,000mcg/ml 15,001mcg/ml up to 20,000mcg/ml 20,001mcg/ml up to 25,000mcg/ml

Up to 20cc

21 to 30cc

31 to 60cc

HYDROMORPHONE

Strengths up to 15mg/ml 15.1mg/ml up to 30.1mg/ml up to 45.1mg/ml up to 60.1mg/ml up to 80.1mg/ml up to 90.1mg/ml up to

Up to 20cc

21 to 30cc

31 to 60cc

30mg/ml 45mg/ml 60mg/ml 80mg/ml 90mg/ml 150mg/ml

KETAMINE

Strengths up to 20mcg/ml 21mcg/ml and up

Up to 20cc

21 to 30cc

31 to 60cc

MEPERIDINE

Strengths up to 50mg/ml 50.1mg/ml up to 100mg/ml 100.1mg/ml up to 200mg/ml

Up to 20cc

21 to 30cc

31 to 60cc

METHADONE

Strengths up to 25mg/ml 25.1mg/ml up to 50mg/ml 50.1mg/ml up to 80mg/ml

Up to 20cc

21 to 30cc

31 to 60cc

MORPHINE

Strengths up to 25mg/ml 25.1mg/ml up to 50mg/ml 50.1mg/ml up to 60mg/ml 60.1mg/ml up to 70mg/ml

Up to 20cc

21 to 30cc

31 to 60cc

ROPIVACAINE

Strengths up to 10mg/ml

Up to 20cc

21 to 30cc

31 to 60cc

PRIALT

CALL FOR PRICING

SUFENTANIL

Strengths up to 50mcg/ml 51mcg/ml up to 100mcg/ml

Up to 20cc

21 to 30cc

31 to 60cc

TETRACAINE

Strengths up to 10mg/ml (1%) 10.1mg/ml up to 20mg/ml (2%)

Up to 20cc

21 to 30cc

31 to 60cc

PLANO - DENTON - TYLER - SAN ANTONIO - EL PASO - MIAMI

Prescribers and Staff

YOUR ONE-STOP SOLUTION AMERICAN SPECIALTY PHARMACY is able to assist you. We are a Specialty Pharmacy with retail stores with the ability to fill ALL of your patient’s medications. Attached you will find a Prescription Referral Form for use with specific chronic illnesses. If your patients also need other medications not listed, just send the prescription along with it and we’ll take care of that too!

Our goal is to service all of the needs of your office and your patients.

• A member of our team will fax prescription and patient status updates throughout the prescription process • P rior authorizations to initiate treatment • R e-Authorization to prevent therapy interruption • C ost management • N o cost for delivery to patient home or your office • I njection training for self injectable medications at patient home or in your office • D isease and treatment education prior to therapy initiation • O ngoing side effects management • C ustomize patient monitoring • R efill reminders and coordination • R etail prescriptions to ensure patients have ONE PHARMACY • I nfusion & Compounding services available For more information please call or email: Phone: (877) 868-4110 | Fax: (888) 294-9434 | Email: info@americanspecialtypharmacy.com

PLANO,TX | DENTON, TX | SAN ANTONIO | EL PASO, TX | TYLER, TX www.AMERICANSPECIALTYPHARMACY.com

We look forward to serving you and meeting all of your pharmacy needs. OUR PRODUCTS & SERVICES

We are a full service pharmacy that specializes in: Compounded & Specialty Medications Durable Medical Equipment (DME) Nutritional Supplementation Workersâ&#x20AC;&#x2122; Compensation Prescriptions Everyday Prescriptions

WE TAKE THE BURDEN OFF OF YOU

Our customer service is second to none; provided by highly trained sta . We assist each patient throughout the entire process. From contacting your insurance carrier to automatic re lls and overnight delivery.

www.AMERICANSPECIALTYPHARMACY.com

At American Specialty Pharmacy, we use the latest technology with top quality ingredients to compound safe and e ective customized medications. Our pharmacists are experts at compounding new, discontinued, back-ordered, or unavailable medications to meet speci c patient needs. We o er a full line of Professional Quality Vitamins,

Nutritional Supplements, OTC Medications, Everyday Prescriptions, Medical Equipment & Specialty Medications.

COMPLIMENTARY DELIVERY All deliveries are delivered straight to your door within 24 hours at no out-of-pocket cost to you.

AUTOMATIC REFILLS

Your re lls are lled automatically based on your prescription or physicianâ&#x20AC;&#x2122;s approval. It is not necessary to reorder!

PLANO LOCATION

2743 West 15th Street Plano, TX 75075 P: 877-868-4110 . F: 877-868-4144

EMAIL

info@americanspecialtyrx.com

HOURS OF OPERATION Mon - Fri 9am until 7pm Sat & Sun 9am until 3pm

www.AMERICANSPECIALTYPHARMACY.com

GROWTH HORMONE

Form

American Specialty to Arrange

Ship to:

Pa ent Home

MD

e

CALL -6877 888)294-9434 EMAIL: info@americanspecialtyrx.com

Treating Patients Special PATIENT INFORMATION (Use this area or

nt demographi s)

Name: ______________________________________ Phone: __________________________ Phone 2: _________________________ Home Address: ________________________________________ City: ____________________ State: _______ Zip: _______________ DOB: ______________ SSN: _________________ Sex: Male Female Height: ____________ Weight: _____________Lbs. Allergies: ________________________________________________________________________________________________________ INSURANCE INFORMATION (Use this area or

opy of insuran

Primary Name: _____________________________________ Phone: ___________________________________________ ID#: _______________________ Group: _______________ MEDICAL ASSESSMENT (Use this area or

ard(s)

Secondary / RX: _____________________________________________ Phone: ____________________________________________________ ID#: _________________________ Group: ______________________

h pa ent labs and other authoriz

Primary Dx: ______________________ ICD9 Code: ___________ Secondary Dx: ______________________ ICD9 Code: ___________ Previous Treatment: ____________________________________ Previous Treatment Outcome:_________________________________ Is currently on Therapy? YES NO Medica s): ____________________________________________________________ PRESCRIPTION INFORMATION *(Use this area or

Genotropin

Humatrope

opy of RX(s)

Cartridge 5mg 12mg Pen 5mg 12mg Mixer Mini Quick Pre ed _______mg

Dose:

Re :

5mg vial Cartridge 6mg 12mg 24mg HumatroPen 6mg 12mg 24mg 40 mg/4mL vial

Leuprolide

5mg/mL 2.8mL mul -dose vial 14 day kit Lupron Depot 3.75mg 11.25mg Lupron Depot Ped 7.5mg 15mg 11.25mg 30mg

Nutropin AQ

Omnitrope

Saizen Tev-Tropin

Flexpro

5mg 10mg Pen 30mg

Re : Qnty: Re :

15mg

Dose:

Qnty: Re : Qnty:

Dose:

Re :

Pen Cartridge 10mg/2mL 20mg/2mL Pen for cartridge 10 20 NuSpin Pre ed 5mg 10mg 20mg 5.8mg vial Cartridge Pen 5

Qnty:

Dose:

Increlex

Norditropin

Qnty:

Dose:

Re : Dose:

5mg/1.5mL 10

Qnty:

10mg/1.5mL

Re :

Vial 5mg 8.8mg CoolClick2 for vials 8.8mg cartridge easypod for 8.8 cartridge One click auto-injector pen 5mg Vial Tjet injector device

Qnty:

Dose:

Qnty: Re : Qnty: Re :

Signature: ______________________________________________

Date: ___________________

Prescriber Name: _____________________________________________ NPI#: ____________________________________ Address: _________________________________ City: __________________________ State: _________ Zip: _________ Phone: ______________________________ Fax: ______________________________ Email: _______________________________________ O ce Contact: __________________________________________

FAX TO: (888) 294-9434

GHFRMVS.912

FEMALE HRT REFERRAL FORM

PRESCRIPTION

PLEASE ATTACH COPIES OF PATIENT’S INSURANCE CARDS C- PERIMENOPAUSAL:

C- PMS:

Progesterone Topical *Apply Cyclically Days 12 – 25 once a day. *Apply BID or TID week prior to period.

Progesterone Topical

C- BI–ESTROGEN TOPICAL:

*Apply Cyclically Days 1 – 25 once a day.

C- PREMENOPAUSAL:

Progesterone Topical *Apply Cyclically Days 12 – 25 once a day. *Apply BID or TID week prior to period.

QTY:

30gm (Thirty Grams)

60gm (Sixty Grams)

C- DHEA ORAL: QTY:

30gm (Thirty Grams)

C- MENO – POSTMENOPAUSAL SURGERY: Progesterone Topical

C- BI–ESTROGEN TOPICAL: *Apply Cyclically Days 1 – 25 once a day. QTY:

30gm (Thirty Grams)

60gm (Sixty Grams)

C- BI – ESTROGEN TOPICAL:

C- TESTOSTERONE TOPICAL QTY: QTY:

30gm (Thirty Grams)

60gm (Sixty Grams)

C- TESTOSTERONE TOPICAL: QTY:

30gm (Thirty Grams)

60gm (Sixty Grams)

SEXUAL DYSFUNCTION ENHANCEMENT:

QTY:

30gm (Thirty Grams)

LIBIDO BOOST CREAM:

N.O.C. AROUSAL CREAM QTY:

30gm (Thirty Grams)

Today’s Date

QTY:

30gm (Thirty Grams)

Prescriber’s Signature

at 888-966-0188

MALE HRT REFERRAL FORM

PRESCRIPTION

Today’s Date

PLEASE ATTACH COPIES OF PATIENT’S INSURANCE CARDS

▢

▢ ▢

▢

Viagra

▢

DESIGNED SUPPLEMENTS & SUPPLIES ▢

▢

TROCHES/TABLETS ▢

▢

CREAM, GEL & ETC - QTY: 30gm (Thrity Grams) ▢

▢

▢ ▢

CREAM, GEL & ETC - QTY: 60ml (Sixty Milliliters) ▢

▢

INJECTABLE - QTY: 10ml (Ten Milliliters) ▢

▢

COMPOUNDED INTRACAVERNOSAL - QTY: 10ml (Ten Milliliters) ▢ ▢ ▢ ▢

ADDITIONAL NOTES:

Prescriber’s Signature at 888-966-0188

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