The Compounding Shoppe

Pain Gel Request

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Please fax my doctor a note requesting a prescription for Ketoprofen Gel for me.

Following is my information:

Name

Birthdate *

Phone # *

Doctor's Name *

Doctor's Phone #

What kind of pain do you have? *

Where is your pain?

How long have you had this pain?

On a scale of 1 to 10, what has been your average pain level in the past 7 days? *

On a scale of 1 to 10, what has been your worst pain level in the past 7 days? *

Please check any boxes below that describe your pain.

Constant Ache

Burning

Sharp/Shooting

Stinging/Tingling

Numbness

What medications are you currently taking for you pain?

Are these medications working well?

Please list any side-effects these medications are causing

What would you be able to do if your pain was decreased by 30%?

We will take this information and fax a note to your doctor requesting a prescription for Ketoprofen Gel for you. When we hear back from the doctor, we will contact you.

( * Required Field )

3349 Highway 31, Suite 102
Homewood, AL 35209
Office 205-870-3150
Fax 205-870-3160
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