PHONE: 208-922-4400 FAX: 208-922-4499
Copyright 2011, Custom Rx, LLC
COPYRIGHT 2012, CUSTOM RX, LLC
Sample Compounded Rx for Prescribers
Rx _________________________________
_________________________________
Compounded Medication
Generic name of active ingredient(s) / Dose or Strength (mg/unit or %)
Dosage Form (e.g. Suppository, Lolli Pop, Transdermal Gel, Cream, Capsule,Troche, etc.)
Quantity
Directions for Use