Compound Pellet & Trocar Order Form BUY DIRECT & SAVE! TROCARS AVAILABLE AT SPECIAL PRICING!! Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.COMPOUNDED PELLET PRESCRIPTIONPatient Name *Patient DOB *Patient AddressStateDate *Patient Phone *CityZipESTRADIOLSTRENGTHSelect Option6mg10mg12.5mg18mg25mg30mg37.5mg50mgQUANTITY12345678910BI-EST PELLETSSTRENGTH10mg15mg20mgQUANTITY12345678910DISPOSABLE STAINLESS STEEL TROCARSPART#Select part numberNEW! - ATROCARTROCAR 1 - Original Design Diamond-Tip OrbutratorTROCAR 2 - Providers Choice Angled-Sharp OrbutratorTrocar 1 Size *3.2mm4.5mmTrocar 2 Size *3.2mm4.5mmTrocar 1 Size *3.6mm5.2mmWould you like to purchase 3.2mm Trocars individually or by the case?Individually at $31.00 each$365.00 per case (12)Would you like to purchase 4.5mm Trocars individually or by the case?Individually at $32.50 each$375.00 per case (12)How many individual units would you like? (Trocar 2 size 3.5mm) How many individual units would you like? (Trocar 2 size 4.5mm)How many cases would you like? (Trocar 2 size 3.2mm)How many cases would you like? (Trocar 2 size 4.5mm) Would you like to purchase 3.6mm Trocars individually or by the case? Individually at $30.00 each$350.00 per case (12)Would you like to purchase 5.2mm Trocars individually or by the case? Individually at $30.00 each$350.00 per case (12)How many individual units would you like? (ATrocar size 3.6mm) How many individual units would you like? (ATrocar size 5.2mm) How many cases would you like? (ATrocar size 5.2mm) How many cases would you like? (ATrocar size 3.6mm) Would you like to purchase Trocar 2 3.5mm individually or by the case?Individually at $36.00 each$425.00 per case (12)Would you like to purchase Trocar 2 4.5mm individually or by the case?Individually at $36.00 each$425.00 per case (12)How many individual units would you like? (Trocar 2 size 3.5mm) How many individual units would you like? (Trocar 2 size 4.5mm)How many cases would you like? (Trocar 2 size 3.2mm)How many cases would you like? (Trocar 2 size 4.5mm) Provider Name *Provider Signature Clear Signature Create PDF