FERTILITYMEDS.COM
Southern California Center for Reproductive Medicine
Robert E. Anderson       Newport Beach, CA 92663
Phone: 949-642-8727 Fax: 949-642-5413
Prior Authorization #:
Name:
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Home:
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ASA 81 mg:
Sig:
Refills:
Aygestin 5mg:
Sig:
Refills:
Cetrotide 0.25mg:
Sig:
Refills:
Climara 0.1mg Patch:
Sig:
Refills:
Dexamethasone 0.5mg:
Sig:
Refills:
Doxycycline 100mg:
Sig:
Take one BID
Days
Refills:
Doxycycline 100 mg:
Sig:
Refills:
Estrace 1mg:
Sig:
DNS
Refills:
Follistim 75IU:
IM:
SQ:
Sig:
Refills:
Gonal-F 75IU:
IM:
SQ:
Sig:
Refills:
Gonal-F 1200IU Multidose Vial:
IM:
SQ:
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Refills:
HCG Profasi 10,000IU
IM:
SQ:
Sig:
Refills:
Heparin 20,000IU
Sig:
Refills:
Lupron - 2 Week Kit
Sig:
DNS
Refills:
Medrol 8mg
Sig:
Refills:
Ovidrel 250mcg
Sig:
Refills:
Pergonal 75IU
IM:
SQ:
Sig:
Refills:
Prednisone
5mg:
10mg:
Sig:
Refills:
Progesterone Capsules Micronized 400mg
Sig:
Refills:
Progesterone in Oil - 50mg/ml 10 ml Vial
Sig:
Refills:
Repronex 75IU
IM:
SQ:
Sig:
Refills:
Serophene 50mg
Sig:
Refills:
Vitamins: Prenate Advance
Sig:
Refills:
Viagra 25mg Capsules
Sig:
Refills:
Other:
Sig:
Refills:
Other:
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Refills:
     
3cc 22g 1 ½" needle
Lupron syringes
 
25g 1" or 1 ½" needle
1 cc syringes
  
27g ½" needle
      
         
CYCLEKIT (FREE injection supplies & Patient Guide)
    
Needle Disposal System (minimal charge) - container includes return postage and biohazard disposal fee
    
Ship to Doctor's Office
    
Anticipated Start Date (REQUIRED
Today's Date
Physician Name
 MD