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Neutrasal prescription form

Prescription form - NeutraSal 2026

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The document is a prescription form for NeutraSal® (Supersaturated Calcium Phosphate Rinse) that includes sections for patient information, prescriber details, insurance information, and prescription specifics. It outlines the necessary steps for submission, eligibility criteria for copay assistance, and terms and conditions related to the prescription and its coverage. The form requires signatures from both the prescriber and the patient to authorize the prescription and the use of protected health information.

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How to use or fill out prescription form - NeutraSal

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Click ‘Get Form’ to open it in the editor.
Begin with the 'Patient Information' section. Fill in the patient's last name, first name, date of birth, and contact details. Ensure the mailing address is accurate for home delivery.
In the 'Practice Information' section, enter the prescriber's name, practice details, and preferred communication method. Don’t forget to include the prescriber’s NPI number.
Next, complete the 'Prescription Benefit Insurance' section by providing the insured's name and relevant insurance details such as drug cardholder ID and group number.
Fill out the 'Primary Medical Insurance' section with similar information regarding medical coverage.
In the 'Prescription' area, specify directions for use and refills as needed. Both prescriber and patient must sign and date at the bottom before submission.

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Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

What is neutrasal?

Neutrasal is a powder that when dissolved in normal tap water becomes a supersaturated calcium and phosphate rinse. Neutrasal was designed in part to replace the normal ionic and pH balance in the oral cavity. Neutrasal also maintains moistness in the oral cavity.

Is neutrasal over the counter?

There is now another product available to patients, but a prescription is needed from a dental or medical professional to obtain it. NeutraSal is a clinically proven rinse to help relieve dry mouth symptoms.

Is neutrasal a prescription?

Nutrafol products are an over-the-counter (OTC) alternative to prescription hair loss medications such as (Propecia), spironolactone (), and ().

Do you need a prescription for artificial saliva?

Try saliva substitutes that contain xylitol and are available without a prescription. These include Mouth Kote or Oasis Moisturizing Mouth Spray.

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