PRESCRIBER’S SIGNATURE DATE · Week 2 (Days 8-14) Week 3 (Days 15-21) Week 4 (Days 22-28) Week 5...
Transcript of PRESCRIBER’S SIGNATURE DATE · Week 2 (Days 8-14) Week 3 (Days 15-21) Week 4 (Days 22-28) Week 5...
Low Dose Naltrexone Order Form
ACHC Accredited Pharmacy Toll-Free Phone 888-290-2244
Direct Phone 201-447-2020 Direct Fax 201-447-3253
PRESCRIBER’S SIGNATURE DATE
Low Dose Naltrexone Titration Starter Kit
1. _______ #1 LDN Starter Kit=(Naltrexone 1.5mg Capsule #63 & Naltrexone 0.5mg Capsule #42) SIG: Take capsules daily prior to bedtime as per starter kit directions
2. _______ Naltrexone (LDN) 0.5 mg Capsule Quantity: 70 (1st month supply) SIG: Start at 1 capsule (0.5 mg) at bedtime and titrate up each week by 1 capsule (0.5 mg) to desired effect or physician specified dose
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Patient’s Name: Prescriber’s Name:
Patient Drug Allergies: Street Address:
Street Address: City, State ZIP:
City, State ZIP: Office #:
Date of Birth: Fax #:
Phone (CELL) #: Email:
Email:
3. _______ Naltrexone (LDN) 0.1 mg Capsule Quantity: 70 (1st month supply) SIG: Start at 1 capsule (0.1 mg) at bedtime and titrate up each week by 1 capsule (0.1 mg) to desired effect or physician specified dose
4. _______ Maintenance Dose: Naltrexone (LDN) 0.1 – 4.5 mg Capsule Quantity: _______________ SIG: Take 1 capsule daily at bedtime or as directed by physician
5. _______ Naltrexone 3% Transdermal Cream Quantity: 30 grams SIG: Apply 4 clicks 3 to 4 times a day to painful areas
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