Office-Use Order Form

Office-Use Order Form

Submit two separate forms if you are ordering more than one product. Special instructions are available at the bottom. After you have submitted your order, if you have any questions call the pharmacy at 843-800-7007. *** If you are a new account, please call the pharmacy to create an account! Thanks!
NOTE: If you have not signed the 2024 Provider Agreement please follow the link below! Thank you for your cooperation! Failure to comply may result in a delay in your shipment.

https://form.jotform.com/240745480417053
Office-Use Price List:
Office Name*
Prescriber Name*
Contact Information*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Delivery Method*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How would you like to be billed?*
Last 4 Digits of CC on file.
For new offices, we will call you to get credit card information.
Credit Card Expiration (for already existing offices only)
What kind of product are you looking for?

Lidocaine 23% Tetracaine 7% in Plasticized BaseOther Numbing CreamsDermatologyDental
Numbing Cream Formulas

Lidocaine 23%/ Tetracaine 7% in Plasticized BaseLidocaine 23%/ Tetracaine 7% in LipodermLidocaine 7%/ Tetracaine 7% in Plasticized BaseLidocaine 23% / tetracaine 7% Topical GelLidocaine 23%/ Tetracaine 7% in White PetroleumLidocaine 30%/ Tetracaine 7% in Plasticized BaseLidocaine 23%/ Tetracaine 7%/ Phenylephrine 0.05% in Plasticized BaseLidocaine 23% / Prilocaine 10% / phenylephrine 0.5% Plasticized BaseLidocaine 23% in Plasticized BaseBenzocaine 20%/ Lidocaine 6%/Tetracaine 4% in VersaproBenzocaine 20%/ Lidocaine 8%/Tetracaine 6% in VersaproBenzocaine 20%/ Lidocaine 10%/Tetracaine 10% in VersaproBenzocaine 20% / Lidocaine 8% / Tetracaine 8% Topical GelBenzocaine 20%/ Lidocaine 10%/Tetracaine 10% in LipodermBenzocaine 20%/ Lidocaine 20%/ Tetracaine 10% in Plasticized BaseLidocaine 23% in Lipoderm (Pregnancy Use)
Dermatology Formulas

Bruise Cream: Phytonadione (Vitamin K)/ Vitamin E/ Phenylephrine/ Sodium Hyaluronate (Hyaluronic Acid)/ Arnica in W06 Anhydrous GelSquaric Acid Dibutyl Ester 2% SolutionCantharidin 0.7% SolutionCantharidin 1%/ Salicylic Acid 30% /Podophyllum 2%Tretinoin 0.3% Solution
Dental Formulas

Lidocaine HCl 10%/ Prilocaine HCl 10%/ Tetracaine HCl 4% Dental GelLidocaine HCl 10%/ Tetracaine HCl 4%/ Prilocaine HCl 10%/ Phenylephrine 0.3% Dental GelLidocaine 20%/ Tetracaine 4%/ Phenylephrine 2% Dental GelLidocaine 10%/Tetracaine HCl 4%/ Phenylephrine 0.2% Dental GelDyclonine 1% Solution
GM or mL Quantity*
Quantity of Containers*
Container*
Color*
Flavor*
Quantity of Container*
Price/GM
Container*
Container*
Special Instructions:
*Prices subject to change. Please indicate if you have any additional requests, clarifications, or packaging specifications. Custom package sizing may accrue additional charges.
Should be Empty:

Office-Use Order Form

NOTE: If you have not signed the 2024 Provider Agreement please follow the link below! Thank you for your cooperation! Failure to comply may result in a delay in your shipment.