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FORMULATION SUBMISSION FORM
Patient Contact Number for Parallel Health via Text: 415-917-1660
Provider Information
This intake form is HIPAA compliant, ensuring that all personal health information submitted is secure and confidential in accordance with federal privacy standards.
Session ID
*
Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date
NPI Number
Office Email
example@example.com
Office Phone Number
Office Address
Clinic Name
Street Address
City
State / Province
Postal / Zip Code
Patient Information
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Allergies
*
Medication
Please select the desired medication(s) from our formulary and specify the appropriate instructions, refills, and quantity. If the desired compounded medication is not available, enter a custom compound in the designated section. We will get back to you and your patient with the cost of the custom formulation.
Acne Formulation
Please Select
Niacinamide/Sodium Hyaluronate/Tretinoin Cream 2%/1%/0.025% (PH1)
Niacinamide/Sodium Hyaluronate/Tretinoin Cream 2%/1%/0.05% (PH2)
Niacinamide/Sodium Hyaluronate/Tretinoin Cream 2%/1%/0.1% (PH3)
Spironolactone Cream 5% (PH4)
Azelaic Acid/Niacinamide Cream 20%/2% (PH5)
Salicylic Acid/Sulfacetamide Na/Sulfur Wash 5%/9%/3% (PH15)
Spironolactone 50 mg Tablets (PH7)
Quantity
Please Select
15g cream ($75)
30g cream ($95)
60g cream ($165)
240 ml wash ($95)
30 tablets ($22)
60 tablets ($26)
90 tablets ($32)
Refills
Please Select
1
2
3
4
5
6
Instructions
Rosacea Formulation
Please Select
Azelaic Acid/Niacinamide/Oxymetazoline Cream 20%/2%/1% (PH14)
Salicylic Acid/Sulfacetamide Na/Sulfur Wash 5%/9%/3% (PH15)
Azelaic Acid/Niacinamide Cream 20%/2% (PH16)
Quantity
Please Select
15g cream ($75)
30g cream ($95)
60g cream ($165)
240 ml wash ($95)
Refills
Please Select
1
2
3
4
5
6
Instructions
Fine Lines and Wrinkles Formulation
Please Select
Niacinamide/Sodium Hyaluronate/Tretinoin Cream 2%/1%/0.025% (PH8)
Niacinamide/Sodium Hyaluronate/Tretinoin Cream 2%/1%/0.05% (PH9)
Niacinamide/Sodium Hyaluronate/Tretinoin Cream 2%/1%/0.1% (PH10)
Quantity
Please Select
15g cream ($75)
30g cream ($95)
60g cream ($165)
Refills
Please Select
1
2
3
4
5
6
Instructions
Melasma/Hyperpigmentation Formulation
Please Select
Azelaic Acid/Niacinamide Cream 20%/2% (PH11)
Hydroquinone/Kojic Acid Cream 8%/2% (PH12)
Fluocinolone/Hydroquinone/Tretinoin Cream 0.01%/8%/0.05% (PH13)
Quantity
Please Select
15g cream ($75)
30g cream ($95)
60g cream ($165)
Refills
Please Select
1
2
3
4
5
6
Instructions
Fungal Acne/Malasezzia Formulation
Please Select
Clotrimazole/ Na Hyaluronate/Niacinamide 2%/1%/2% Cream (PH17)
Quantity
Please Select
15g cream ($75)
30g cream ($95)
60g cream ($165)
Refills
Please Select
1
2
3
4
5
6
Instructions
Eczema Formulation
Please Select
Aloe/Colloidal Oatmeal/Triamcinolone Acetonide 4%/2%/0.025% (PH20)
Aloe/Colloidal Oatmeal/Triamcinolone Acetonide 4%/2%/0.05% (PH21)
Aloe/Colloidal Oatmeal/Triamcinolone Acetonide 4%/2%/0.1% (PH19)
Quantity
Please Select
30g cream ($135)
60g cream ($245)
Refills
Please Select
1
2
3
4
5
6
Instructions
Hidradenitis Suppurativa Formulation
Please Select
Azelaic Acid/Colloidal Oatmeal/Na Hyaluronate/Zinc Oxide Cream 15%/2%/0.25%/10% (PH18)
Quantity
Please Select
30g cream ($135)
60g cream ($245)
Refills
Please Select
1
2
3
4
5
6
Instructions
Custom Formulation
Quantity
Refills
Please Select
1
2
3
4
5
6
Instructions
SUBMIT APPROVAL
Should be Empty: