Anaesthetic Cream/Gel Enquiry Form Anaesthetic Cream/Gel Enquiry Form S2/S3 FORM Enquiry Form Please ensure you complete this form with YOUR details, Once completed our staff will be in contact to discuss if we have a suitable product. THIS FORM IS NOT AN ORDER FORM – A PHARMACIST IS REQUIRED TO ENSURE THE CORRECT PRODUCT IS RECOMMENDED. EACH PRODUCT IS COMPOUNDED AFTER CONFIRMATION OF YOUR DETAILS Patient First Name * First Patient Last Name * Last Address: * Suburb * State * QLDNSWVICSAWANTTASACT Post Code * Mobile Number * Date of Birth * Email * Would you be wanting Pickup or Delivery? * Please POST this product TO ME Please POST this product to MY CLINIC FOR TREATMENT I will COLLECT from ACPHARM ( 20 Central Park Ave, Ashmore QLD 4214) CLINIC NAME * Clinic Address * Clinic Suburb * Clinic Post Code * I confirm: * I consent for the Pharmacy compounding my medication to contact me to confirm my medical history or payment details. I confirm: * This medication is only to be used by the person that is listed as the Patient and will not be supplied/used on anyone else I confirm: * I consent for the Pharmacy compounding my medication to contact me to confirm my medical history or payment details. Clinic or Person’s name providing your treatment * Treatment being performed * Skin NeedlingCosmetic TattooOther Treatment being performed Treatment Date Product Required * Numbing Gel or Cream Type of Numbing required * Pre-treatment – NOT FOR BROKEN SKIN During Treatment – CAN BE USED ON BROKEN SKIN PRE TREATMENT RECOMMENDED BY PRACTITIONER * PRE-NUMB #1 – Prilocaine 2.5%, Lidocaine 2.5%, Tetracaine 4% in ACPHARM WATERLESS GEL BASEPRE-NUMB #2- Lidocaine 4.5% Tetracaine 4.5% in ACPHARM WATERLESS GEL BASETLA Cream – Prilocaine 1.5%, Lidocaine 1.5%, Tetracaine 4% in ACP Pain Block BaseOther PRE TREATMENT RECOMMENDED BY PRACTITIONER DURING TREATMENT RECOMMENDED RECOMMENDED BY PRACTITIONER * WEAK BROKEN-NUMB – Lidocaine HCL 2%, Tetracaine HCL 2%, Epinephrine 0.02% Aqueous Gel (Eyeline)BROKEN-NUMB – Lidocaine HCL 6%, Tetracaine HCL 4%, Epinephrine 0.05% Aqueous GelSTRONG BROKEN-NUMB – Lidocaine HCL 6%, Tetracaine HCL 4%, Epinephrine 0.1% Aqueous GelOther DURING TREATMENT RECOMMENDED RECOMMENDED BY PRACTITIONER Do you have a prescription for this item? * Yes No Please upload the prescription – We will need to receive the original before we can send Drop a file here or click to upload Choose File Maximum file size: 60MB Quantity Required (Price will be advised) * 10 Grams 30 Grams 50 Grams Are you Pregnant or Breastfeeding? No Yes Do have a heart condition of any type? No Yes Do you have any allergies? No Yes Please list all Allergies * Have you used a topical Anaesthetic before? * No Yes – When was the last time?Yes – When was the last time? Do you have any other Medical Conditions? No Yes Please list any medical conditions * Do you take any current medications? No Yes Please list any medications you are currently taking * IMPORTANT: A Patch test should be performed at least 24 hours before use- Apply a small amount to the inside of the arm and leave on for 20 minutes- If no skin reaction (Redness/Itching/Swelling/Stinging) then it should be safe to use. * I confirm that I will perform a Skin Patch Test before using this product Order Notes Patient Signature * signature keyboard Clear I confirm that all the information provided is true and correct and I agree that l will be contacted by ACPHARM about this enquiry Submit If you are human, leave this field blank. Δ
