NUMBING CREAM ORDER FORM

compounding with confidence

S2/S3 numbing request

For numbing gels and creams used with skin needling, cosmetic tattoo and similar treatments. Takes about 5 minutes.

This is a request, not an order

A pharmacist checks every request to make sure the right product is recommended. We compound your product only after we’ve confirmed your details.

1Your details

Fill this in with your own details — the person who will use the product.

We’ll call you on this number.

2Delivery or collection

How would you like to receive it?

3Your treatment

4Product

Product 1

When will the numbing product be used?
Quantity

Price per tube. Postage is extra.

Product 2

When will the numbing product be used?
Quantity

Price per tube. Postage is extra.

Product 3

When will the numbing product be used?
Quantity

Price per tube. Postage is extra.

Do you have a prescription for this product?

Photo of your prescription optional

We need the original prescription before we can send your product.

JPG, PNG, HEIC or PDF, up to 10 MB.

    5Health questions

    The pharmacist uses these to check the product is safe for you.

    Are you pregnant or breastfeeding?
    Do you have a heart condition of any kind?
    Do you have any allergies?
    Do you have any other medical conditions?
    Do you take any medications?

    Include vitamins and supplements.

    Have you used a topical anaesthetic before?

    6Confirm and sign

    Do a patch test first

    At least 24 hours before use, apply a small amount to the inside of your arm and leave it on for 20 minutes. If there’s no redness, itching, swelling or stinging, it should be safe to use.

    I confirm the information I’ve given is true and correct, and I agree ACPHARM may contact me about this request.

    Sign with your finger or mouse.

    Privacy notice

    ACPHARM collects the personal and health information provided in this form to identify the patient, review and process the prescription, assess medication safety, dispense or compound medication, contact the patient or prescriber where necessary, process payment, arrange delivery or collection and meet our pharmacy and legal obligations.

    We may disclose information where reasonably necessary to prescribers and other healthcare providers, pharmacy and electronic prescription service providers, payment providers, IT service providers, couriers and regulatory authorities.

    If you do not provide information required to safely and lawfully dispense your prescription, we may be unable to process your order.

    For information about how ACPHARM stores, uses and protects personal information, overseas disclosures, and how to access, correct or complain about your information, please read our Privacy Policy.