prescriber compounding

SlimWell Rx™ — Electronic Prescription Pad | Erdman Pharmacy

4532 Erdman Avenue, Baltimore, MD 21213 Phone: 410-488-5091 | Fax: 866-528-5343 support@erdmanpharmacy.com | erdmanpharmacy.com

Patient Information

Patient Full Name

Date of Birth

Sex

Address

Phone

Allergies

Prescriber Information

Prescriber Full Name

NPI #

DEA #

State License #

Practice / Clinic Name

Practice Phone

Practice Fax

Prescription

℞

SlimWell Rx™ — Compounded Weight Loss Capsule

Erdman Pharmacy Compounding — verify strengths and confirm formula prior to dispensing

Active Ingredient

Strength / Dose

Unit

Phentermine HCl

Topiramate

Green Tea Extract

Chromium

Methylcobalamin (B12)

Sig (Directions for Use)

Quantity

Days Supply

Refills

Date Written

Dispense As Written / Medically Necessary Substitution Permitted

⚠ Phentermine HCl is a DEA Schedule IV controlled substance. Depending on your state and payer, this prescription may require submission through an EPCS-certified (Electronic Prescribing of Controlled Substances) platform rather than a standard web form or fax. This document is provided as a compounding order / prescriber communication tool — please confirm it satisfies your state's e-prescribing and controlled-substance requirements before relying on it as the prescription of record. A wet or EPCS-compliant electronic signature may still be required.

Prescriber Authorization

Signature

Print Prescriber Name

Date Signed