Follow the steps to complete the Ointment order form online.

1. Press the ‘Get Form’ button to access the Ointment form and open it in your preferred digital environment.
2. Begin by entering the clinic information at the top of the form. Fill in the clinic name, phone number, fax number, and complete address.
3. In the patient information section, provide the patient's full name, date of birth, social security number, address, and phone number.
4. To proceed, attach a copy of the prescription drug insurance card or Medicaid card as indicated.
5. Under the patient diagnosis and wound size section, enter the diagnosis code followed by detailed wound information. For each wound, specify the dimensions in centimeters and the corresponding location.
6. Next, move to the prescription information section. Indicate the drug as Ointment (250 units/g) and specify the size of the tube required (30 gm or 90 gm).
7. Complete the dosage instructions in the 'Sig' field by noting the frequency of application, which could be once daily or more often if the dressing becomes soiled, and the duration of usage.
8. Indicate the quantity needed based on the number of days the treatment will last and provide the number of refills, if applicable.
9. Lastly, ensure that the prescriber’s signature, NPI number, and date are included before finalizing the form.
10. Once you have filled out all necessary sections, save any changes made, and then download, print, or share the completed form as required.

Complete your documents online for a more streamlined ordering process.