Anaesthetic Cream/Gel Order Form Anaesthetic Cream/Gel Order Form S2/S3 FORM Order Form Please ensure you complete this form with YOUR details (The Person who will be using the product), Once completed our staff will be in contact to organise payment and to confirm pick up or delivery of your order Patient First Name * First Patient Last Name * Last Address: * Suburb * State * QLDNSWVICSAWANTTASACT Post Code * Mobile Number * Date of Birth * Email * Pickup or Delivery? * Please POST this product TO ME I will COLLECT from ACPHARM ( 20 Central Park Ave, Ashmore QLD 4214) 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 Numbing Requested Medicine * Pre-Numb Gel #1 – Prilocaine 2.5%, Lidocaine 2.5%, Tetracaine 4% in ACPHARM WATERLESS GEL BASEPre-Numb Gel #2- Lidocaine 4.5%, Tetracaine 4.5% in ACPHARM WATERLESS GEL BASETLA NUMB CREAM – Prilocaine 1.5%, Lidocaine 1.5%, Tetracaine 4% in ACPHARM Pain Block BaseEyeline Tattoo Numbing Gel – Tetracaine 2%, Lidocaine 5% in Uni-base creamOther Requested Medicine During Treatment Numbing Requested Medicine * Weak Broken Numb – Lidocaine HCL 2%, Tetracaine HCL 2%, Epinephrine 0.02% in Aqueous Gel (Best for Eyeline tatooing)Mild Broken Numb – Lidocaine HCL 6%, Tetracaine HCL 4%, Epinephrine 0.05% in Aqueous GelStrong Broken Numb – Lidocaine HCL 6%, Tetracaine HCL 4%, Epinephrine 0.1% in Aqueous GelOther Requested Medicine 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 use 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 * Clear Submit If you are human, leave this field blank. Δ
