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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.
Format: (000) 000-0000.
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 / Scarring Formulations
Please Select
Niacinamide 2%/Sodium Hyaluronate 1%/Tretinoin 0.05% Cream (PH2)
Niacinamide 2%/Sodium Hyaluronate 1%/Tretinoin 0.1% Cream (PH3)
Spironolactone Cream 5% (PH4)
Azelaic Acid 20%/Niacinamide 2% Cream (PH5)
Adapalene 0.1%/Azaleic Acid 15%/Niacinamide 2% (PH23)
Adapalene 0.3%/Azaleic Acid 20%/Niacinamide 4% (PH24)
Quantity
Please Select
15g cream ($95)
30g cream ($135)
60g cream ($195)
Refills
Please Select
1
2
3
4
5
6
Instructions
Rosacea Formulations
Please Select
Azelaic Acid 20%/Niacinamide 2%/Oxymetazoline 1% Cream (PH14)
Azelaic Acid 20%/Ivermectin 1%/Niacinamide 2% Cream (PH16)
Quantity
Please Select
15g cream ($95)
30g cream ($135)
60g cream ($195)
Refills
Please Select
1
2
3
4
5
6
Instructions
Fine Lines and Wrinkles Formulations
Please Select
Niacinamide 2%/Sodium Hyaluronate 1%/Tretinoin 0.025% Cream (PH8)
Niacinamide 2%/Sodium Hyaluronate 1%/Tretinoin 0.05% Cream (PH9)
Niacinamide 2%/Sodium Hyaluronate 1%/Tretinoin 0.1% Cream (PH10)
Tazarotene 0.05%/Sodium Hyaluronate 1%/Niacinamide 2% (PH25)
Quantity
Please Select
15g cream ($95)
30g cream ($135)
60g cream ($195)
Refills
Please Select
1
2
3
4
5
6
Instructions
Melasma/Hyperpigmentation Formulation
Please Select
Azelaic Acid 20%/Kojic Acid 2%/Niacinamide 2% Cream (PH11)
Fluocinolone 0.01%/Hydroquinone 8%/Tretinoin Cream 0.05% (PH13)
Fluocinolone 0.01%/Hydroquinone 4%/Tretinoin Cream 0.025% (PH26)
Fluocinolone 0.01%/Hydroquinone 6%/Tretinoin Cream 0.025% (PH27)
Quantity
Please Select
15g cream ($95)
30g cream ($135)
60g cream ($195)
Refills
Please Select
1
2
3
4
5
6
Instructions
Fungal Acne/Malasezzia Formulation
Please Select
Clotrimazole 2%/Sodium Hyaluronate 1%/Niacinamide 2% Cream (PH17)
Quantity
Please Select
15g cream ($95)
30g cream ($135)
60g cream ($195)
Refills
Please Select
1
2
3
4
5
6
Instructions
Eczema Formulation
Please Select
Aloe 4%/Colloidal Oatmeal 2%/Triamcinolone 0.05% (PH21)
Aloe 4%/Colloidal Oatmeal 2%/Triamcinolone 0.1% (PH19)
Quantity
Please Select
15g cream ($95)
30g cream ($135)
60g cream ($195)
Refills
Please Select
1
2
3
4
5
6
Instructions
Hidradenitis Suppurativa Formulation
Please Select
Azelaic Acid 15%/Colloidal Oatmeal 2%/Sodium Hyaluronate 0.25%/Zinc Oxide 10% Cream (PH18)
Quantity
Please Select
15g cream ($95)
30g cream ($135)
60g cream ($195)
Refills
Please Select
1
2
3
4
5
6
Instructions
Hair Growth Formulation
Please Select
Dutasteride 0.3%/Minoxidil 5%/Tretinoin 0.0125% (HL3)
Dutasteride 0.3%/Minoxidil 10%/Tretinoin 0.0125% (HL4)
Quantity
Please Select
30g solution in suspension ($135)
60g solution in suspension ($195)
Refills
Please Select
1
2
3
4
5
6
Instructions
Neuropathic Itch
Please Select
Amitriptyline 2%/Gabapentin 10% (PH22)
Quantity
Please Select
15g cream ($95)
30g cream ($135)
60g cream ($195)
120g cream in jar
240g cream in jar
Refills
Please Select
1
2
3
4
5
6
Instructions
Custom Formulation
Quantity
Please Select
15g cream
30g cream
60g cream
Refills
Please Select
1
2
3
4
5
6
Instructions
Would you like to recommend any of the following microbiome-supportive products to supplement your patient's prescription?
Holy Calming Cleanser
Blue Biotic™ Multi-Effect Peptide Cream (Anti-Aging/Advanced Skin Healing)
Skin Barrier Silk Cream (Age Prevention/Skin Barrier Protection)
Facial Skin Microbiome Testing
Body Blemish Microbiome Testing
Scalp Microbiome Testing
Odor Microbiome Testing
None
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