AMERICAN RESPIRATORY SOLUTIONS
1225 North Summit St., Crescent City, FL 32112
Phone: 888.224.6133 / Fax: 888.224.6129

PATIENT NAME:____________________________________ D.O.B.___ /___/___ SEX:       M F

ADDRESS:_________________________________________S.S. # _________________________

__________________________________________________PHONE: ( _____ ) ________________

DIAGNOSIS____________________________________________________________

PRESCRIPTION: SPECIAL INSTRUCTIONS QUANTITY Lev-Albuterol 1.25mg + Ipratropium 0.5mg/ 3ml   Lev-Albuterol 1.25mg + Ipratropium 0.5mg + Budesonide 0.5mg/ 3ml   Lev-Albuterol 1.25mg + Budesonide 0.5mg/ 3ml   Lev-Albuterol 0.63mg + Ipratropium 0.5mg/ 3ml   Xopenex 1.25mg/ 3ml   Duoneb / 3ml   Albuterol 2.5mg/ 3ml   Ipratropium 1.5mg/ 2.5ml   Other Products   INDICATE NUMBER OF STARTER DOSE VIALS GIVEN TO PATIENT IN THE OFFICE:  ____________ SIG:_______ QD     BID     TID    QID    Q4H    Q6H     Q8H    OTHER NUMBER OF REFILLS:     PRN    1    2    3    4    5    6    OTHER ________ NEBULIZER UNIT SERIAL # _____________________     RENTAL     PURCHASE    LOANED PHYSICIAN’S SIGNATURE: ______________________________________________ Date ___ /___ /___ PHYSICIAN INFORMATION: NAME (Print): ____________________________________DEA# _____________UPIN# _____________ ADDRESS:____________________________________________PHONE: ( _____ ) ________________ INSURANCE INFORMATION: PRIMARY INS:____________________________    SECONDARY INS: __________________________ INS ADDRESS:___________________________     INS ADDRESS: _____________________________ ________________________________________      __________________________________________ INS PHONE: ( _____ ) _____________________     INS PHONE: ( _____ ) ________________ NAME OF INSURED:______________________     NAME OF INSURED:_________________________ POLICY# ________________________________     POLICY#___________________________________ GROUP# ________________________________     GROUP#___________________________________