herbal compounding

MetaFirm™ — 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 #

State License #

Practice / Clinic Name

Practice Phone

Practice Fax

Prescription

℞

MetaFirm™ Glycemic Core — Compounded Metabolic Capsule

Erdman Pharmacy Compounding — Size 00 capsule, 750 mg total fill weight — verify strengths and confirm formula prior to dispensing

Active Ingredient

Strength / Dose

Unit

Green Tea Extractstandardized EGCG

Berberine HCl

Artichoke Leafstandardized Cynarin

ForskolinForsLean®

Gymnemic AcidsGS4 Plus®

Milk Thistlestandardized Silymarin

Cayenne

PiperineBioPerine®

Chromium PicolinateUSP grade

Sig (Directions for Use)

Quantity

Days Supply

Refills

Date Written

Dispense As Written / Medically Necessary Substitution Permitted

ℹ MetaFirm™ Glycemic Core is a compounded nutraceutical formula — all nine actives are standardized botanicals and nutrients, not DEA-scheduled substances. This order can be submitted as a standard compounding prescription. Please confirm patient-specific dosing (particularly Berberine HCl) against current metformin-comparator and drug-interaction guidance before signing.

Prescriber Authorization

Signature

Print Prescriber Name

Date Signed