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1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your personal information in the 'Patient Information' section. Fill in your name, date, address, city, state, zip code, phone number, email, and date of birth.
3. Select the type of TriMix you wish to order by checking the appropriate box. Options include TriMix Standard, TriMix Plus, TriMix Super, Quad Mix, Custom formulation, or Phenylephrine.
4. Indicate the dispense quantity by circling either 5ml, 10ml or writing a custom amount in the provided space.
5. If needed, check any additional items such as syringes and alcohol swabs.
6. For physicians interested in joining Olympia Pharmacy's database for prescribing TriMix, check the corresponding box and provide your details including name, NPI#, license#, and signature.

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