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Compounding Pharmacy Patient Enrollment
Registration

Compounding Pharmacy Patient Enrollment

2 pages•17 fields•HIPAA-ready
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Compounding Pharmacy Patient Enrollment
Patient Full Name
Date of Birth
Phone Number
Email Address
Prescribing Physician
Type of Compound Needed
Select...
Known Drug Allergies
Inactive Ingredient Sensitivities
Preferred Dosage Form
Select...
Flavoring Preference (Pediatric)
Select...
Submit
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This compounding pharmacy enrollment form captures comprehensive patient information necessary for safe preparation of customized medications including hormone replacement therapy, pediatric suspensions, veterinary compounds, dermatological preparations, and pain management formulations. The form collects detailed allergy profiles, inactive ingredient sensitivities, dye-free requirements, and preferred dosage forms (capsules, troches, transdermal creams, suppositories). It includes insurance verification for covered compounds and coordination with prescribing providers.

Designed for independent compounding pharmacies and specialty practices, this registration template documents patient preferences for flavoring agents, strength adjustments, and combination therapies. It captures auto-refill preferences, delivery or pickup options, and refrigeration capabilities for temperature-sensitive compounds. The form includes consent for pharmacist consultation, compliance with state board regulations, and financial policies for non-insurance covered custom formulations. It streamlines the intake process while ensuring regulatory compliance for USP 795 and 797 standards.

What's included

  • Patient demographics and contact information
  • Prescribing provider details
  • Comprehensive allergy and sensitivity screening
  • Preferred compound formulation type
  • Flavoring and customization preferences
  • Insurance and payment information
  • Delivery or pickup preferences
  • Auto-refill program enrollment
  • Refrigeration storage capability
  • Pharmacist consultation consent

Who uses this template

  • Independent Compounding Pharmacies
  • Hormone Therapy Clinics
  • Pediatric Specialty Practices
  • Veterinary Compounding Services
  • Integrative Medicine Centers

All form fields

10 fields across 2 pages. Customize any field after signing up.

Patient Full NameText
Date of BirthDate
Phone NumberPhone
Email AddressEmail
Prescribing PhysicianText
Type of Compound NeededDropdown
Known Drug AllergiesAllergies
Inactive Ingredient SensitivitiesLong Text
Preferred Dosage FormDropdown
Flavoring Preference (Pediatric)Dropdown
8 min saved per patient98% patient satisfaction3x faster than paper

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