The Compounding Shoppe

Request for PF Gel

Please fax my doctor a note requestion a prescription for PF Gel for my plantar fasciitis for me.

My name is:

My birthdate is:

My Address is:

Doctor's Name

Doctor's Phone #

How long have you had this pain?

What has been your AVERAGE pain level in the past 7 days?

mild moderate severe

What has been you WORST pain level in the past 7 days?

mild moderate severe

Please list any medications you are currently taking for your plantar fasciitis pain:

Are they working well?

Are they causing any side-effects?

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

We will take this information and fax a note to your doctor requesting a prescription for PF Gel 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