Description
BHRT Compounding Enrollment Form is a generic pre-fabricated enrollment form for specialty pharmacies to use when enrolling patients in BHRT compounding treatment.
The form includes the following sections:
- Heading – pharmacy can input their contact details manually or electronically
- Patient Information – personal information of the patient
- Prescriber Information – Practice details
- Clinical Information – diagnosis
- Compounded Prescription Information
- Custom Formula – prescriber can enter a custom formulary
- Prescriber Signature – includes a disclaimer
The Compounded Prescription Information section includes the following medications:
- Biest
- Progesterone
- Estriol Vaginal Suppositories
- Oxytocin Sublingual Tabs
- Hormone-free Vaginal Moisturizer
- Estriol/Hyaluronic Acid
- Scream Cream
- Thyroid MR Caps
- Thyroid (Synthetic)
- Testosterone
