BHRT PRESCRIPTION FORM

Patient Name: _______________________________________________________________________________

Date: _____________________________
Gender: Male / Female IC/Passport No: __________________________________Date of Birth: _________________________
Address: ____________________________________________________________________________________________________________________
Postcode: ____________________________________
City: _______________________________________________
Country: _____________________________
Contact No: _________________________________
Email: ________________________________________________
Allergies: __________________________

Please tick ( √ ) in the appropriate boxes

Preparation Form Dose/ Strength Frequency Qty
Male Female
□ DHEA Micronized SR Oral Capsules □ 25mg □ 5mg # 100
□ 50mg □ 10mg Take 1 capsule daily in the morning Refills: ____
□ 75mg □ 15mg
□ Others: ________ mg

Male Female □ Male

□ Testosterone Cream □ 100mg (20%) □ 5mg (2%) Apply ONE pump daily to upper inner arm/thigh 50g/100g
in the morning and evening
□ 50mg (10%) □ 2.5mg (1%) □ Female
Apply ONE pump daily to upper inner arm/thigh 30g
□ Others: ________ mg Refills: ____

Dose (mg): Take 1 capsule daily at least 1 hour before

□ Melatonin Oral Capsules bedtime # 100
□1 □2 □3
Micronized SR □ Increase dose as needed. Max ____ caps/day Refills: ____
□ Others: ________ mg

Dose (mg):
□ Pregnenolone SR Oral Capsules Take 1 capsule daily in the morning # 100
□ 25 □ 50 □ 75
Refills: ____
□ Others: ________ mg

□ Progesterone □ Sublinguals □ 100mg □ Place 1 sublingual under the tongue in the # 100
□ Oral Capsules □ Others: ________ mg morning AND/OR evening. Refills: ____
□ Take 1 capsule daily at bedtime

□ Bi-estrogen □ Oral Capsules Dose (mg): # 100 (OR)

□ Creams Estradiol: _________ mg Take 1 capsule daily in the morning 30g
Estriol: _________ mg Refills: ____

Dose (mg):
□ Thyroid (Desiccated) Oral Capsules □ 1/2 gr □ 1 gr Take 1 capsule daily in the morning on empty # 100
□ Others: ________ gr stomach Refills: ____
□ T3 / T4 T3: ________ mcg Avoid Ca containing products
T4: ________ mcg

□ Vitamin D3 □ Oral Capsules □ 5,000IU □ Take 1 capsule daily in the morning with food # 100
□ CCE Solution □ Others: ____________ IU □ Take ____________ml daily 50ml

Others: □ Oral Capsules Please state: # 100 (OR)

______________________ □ Sublinguals ______________ mg/IU ___________________________________________ _______ g
□ Creams Refills: ____

Total Medication: ___________

Remark (s) If any: ______________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________

FOR OFFICE USE ONLY

INV
__________________________________________ _____________________________________________ DIS
Physician's Signature Physician's Official Stamp REP
Accent Wellness Compounding Pharmacy, Lots S22-23&S29, 2nd Floor, SJMC (North Tower Annexe Block), 1 JLN SS12/1A, 47500, Subang Jaya, Selangor
Tel: 03-56391400 Fax: 03-56391401
SAL/P01/F01 Rev 0