inhalED – NuevistraMed

Prescriber No. & NPI:

Supervising Physician & NPI

Clinic Name & Contact:

Phone

Address

City, State, ZIP:

Patient Name

Date of Birth

Address

Phone

City, State, ZIP:

Allergies

Checkboxes

Checkboxes (copy)

(20MG Sildenafil per capsule)

Checkboxes

1 inhaler and 7 capsules (20ml sildenafil per capsule)

Checkboxes (copy)

2 inhaler and 4 capsules (20ml sildenafil per capsule)

Submitted By

By signing this order, the provider attest to the patient’s CLINICAL need for inhaled sildenafil compound.

Phone of (copy)

Physician Signature

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Date