Richard Wagner

 
 2020 Sep 01 FROM- CWFMD 
 936-703-5455 
 T-256 P0034/0111 F-240 
 TOPICAL PAIN FOCUSED 
 Richie's 
 Toll Free Phone 
 SPECIALTY PHARMACY 
 Toll Free Fax
 Patient's Name:
 Richard Wagner 
 Prescriber's Name: 
 JOSHUA DUBOSE 
 Street Address: 
 14570 TRERO LANE 
 Street Address: 
 804 W MONTGOMERY 
 City, State ZIP: 
 WILLIS TX 77378 
 City, State ZIP: 
 WILLIS TX 77378 
 BIRTHDATE: 
 2003 Nov 20 
 Office #: 
 936.890.8000 
 Phone #: 
 xxx.yyy.zzzz 
 Fax #: zzz.zzz.zzzz 
 Additional Contact #: 
 Patient Allergies: 
 PRESCRIBER'S SIGNATURE: X 
 DATE: 
 2014 Jun 19 
 Commonly Requested Medications: (CMRD references a Medication Compounded by Pharmacy, TC 
 references a Topical Cream, CA references a Commercially Available Medication) 
 1. 
 CMPD Diclofenac Sodium 0.15% Lid贸caine 2.25% Prilocaine 2.25%TC (1740) 
 Directions: (Directions selected below apply to all medications indicated above - please check desired dosing) 
 Apply 4 grams three to four times daily for treatment of pain - DISPENSE #480 (FOUR-HUNDRED- 
 EIGHTY) GRAMS FOR 30 DAY SUPPLY (PAINNORM) 
 OTHER 
 I authorize pharmacy to dispense any of the checked medications below. In fleu of medication checked above, If 
 desired by the patient for any reason 
 CMPD Flurbiprofen 10%, Cyclobenzaprine 1% in LAM* (1667) DISPENSE #120 GRAMS - Apply 2 to 4 
 grams three to four times daily for treatment of pain (PAINDLP) 
 Refills: (Number of refills indicated here refers to all medications prescribed above and below) 
 1 Year 
 5 
 3 
 1 
 Zero 
 Name: Richard Wagner 
 DOB: 2003 Nov 20 
