Testosterone Pellets Order Form
Patient Information
Name
*
Date of Birth
*
/
Month
/
Day
Year
Date
Phone
*
Alt Phone
Address
City
State
Zip
Rx Information
*
Testosterone Pellets
*
12.5mg
27.5mg
50mg
100mg
QTY
*
Refills
*
Diagnosis
*
ICD-10
*
SIG
*
Provider Information
Name
*
Signature
*
Date
*
/
Month
/
Day
Year
Date
NPI
*
DEA
*
Phone
*
Fax
Address
*
City
*
State
*
Zip
*
Email
For copy of submitted Rx form, password protected. Obtain password from pharmacy.
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