The Compounding Shoppe

Pain Consult Request

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Please fax my doctor a note requesting a prescription for a pharmacy pain consult.

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 your 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 your worst pain level been in the past 7 days?

What medications are you currently taking for your pain?

Are these medications working well?

Please list any side-effects these medications are causing

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

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