Pharmacy Solutions - RX Compound

817.274.0050

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Men Health

Men's Health Order Form

Fill out the order form below or download and manually fill in the form.

PATIENT INFORMATION

ALPROSTADIL

Product Injectable
Empty Product Injectable

PAPAVERINE, PHENTOLAMINE

Product Bi-Mix
Product Bi-Mix
Empty Product Bi-Mix

PAPAVERINE, PHENTOLAMINE, PROSTAGLANDIN E1 (PGE1)

Product Tri-Mix
Product Tri-Mix
Product Tri-Mix
Product Tri-Mix
Product Tri-Mix
Product Tri-Mix
Product Tri-Mix
Empty Product Tri-Mix

PAPAVERINE, PHENTOLAMINE, PROSTAGLANDIN E1 (PGE1),ATROPINE

Product Quad-Mix
Empty Product Quad-Mix
SIG

as measured on syringe intercavernously.

ORAL PRODUCTS

Product Oral
Product Oral
Product Oral
Product Oral
Product Oral
SIG

tablets 30 minutes prior to sexual activity

NASAL SPRAY

Product Nasal
SIG: 1-2 sprays in nostril prior to sex

TOPICAL HORMONE REPLACEMENT CREAM

Product Topical
SIG: Apply 1gm to upper arm or shoulder daily.

PHYSICIAN INFORMATION

Clear Signature

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Pharmacy Solutions - RX Compound

Pharmacy Solutions
1921 W Pioneer Pkwy,
Arlington, TX 76013

Click here for driving directions.

Pharmacy Solutions - RX Compound

ATTENTION!

YOUR FORM IS NOT SUBMITTED

To submit your order, click the “PRINT/SAVE” button located under this pop-up. 

Print and Save

You can save the PDF to your computer to fax at a later date or print it now to fax immediately.  

Printing Copy Save

Fax your order form to 817-860-6083 for processing.

Pharmacy Solutions - RX Compound

GLP1s available in all states EXCEPT:

Alabama |
Arkansas
| California
| Michigan
Massachusetts 
| Mississippi
| New Jersey | 
Nevada

ARIZONA | COLORADO | FLORIDA | GEORGIA 
 ILLINOIS | Kansas KENTUCKY | LOUISIANA MISSOURI | NEW YORK OKLAHOMA 
 Pennsylvania | TEXAS

If you have any questions, please call us.

TOLL-FREE: 800-542-5767
PHONE: 817-274-0050

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