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Click ‘Get Form’ to open the TriMix EXPERTS RX form in the editor.
Begin by filling out the Patient Information section. Enter your name, date, address, city, state, zip code, phone number, email, and date of birth in the designated fields.
Select your shipping preference by checking either 'Patient Address' or 'Office Address'. Remember that TriMix must be kept cool and will be shipped to arrive next business day.
Choose your desired TriMix formulation from the options provided. You can select from Standard, Plus, Super, Quad Mix, or Custom formulations based on your needs.
Indicate the dispense quantity by selecting either 5ml or 10ml. If you require additional items like syringes or alcohol swabs, check those options as well.
Complete the Signature section by entering the physician's name, license number, phone number, address, and signature. Don’t forget to specify the number of refills required.
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