Get Custom Compounded Pfg Amp Dyc Fax Order Form

Filling out the Custom Compounded PFG Amp DYC FAX ORDER FORM online is a straightforward process. This guide will walk you through each section of the form, ensuring that you provide the necessary information accurately and efficiently.

Follow the steps to complete the form accurately.

1. Press the ‘Get Form’ button to obtain the form and display it in the editing interface.
2. In the first section, fill out the provider's name and credentials (e.g., DDS) in the 'Name' field. Ensure that all required fields are completed accurately.
3. Provide the complete address in the designated fields, including suite number, city, state, and ZIP code.
4. Enter the telephone number for the contact person, ensuring it is a valid number.
5. Input the DEA number and state license number in the respective fields. This information is necessary for compliance with regulations.
6. Proceed to the payment information section. Fill in the credit card number along with the expiration date and CVV2 code.
7. Select the shipping information according to your needs, specifying whether the shipment is inside or outside California, and any additional shipping options if applicable.
8. Choose the compounded PFG product options and indicate the quantities in the provided fields. Be sure to select any special options or flavors desired.
9. For additional compound options, indicate the quantities next to your selected flavors and options as needed.
10. Complete the total calculations by entering the total number of tubes and jars you are ordering.
11. In the DYC Topical Anesthetic Rinse section, indicate the quantities and flavors for the selected products.
12. Finally, ensure you sign and date the form at the bottom to validate the order, confirming compliance with regulations regarding compounded orders.
13. After completing all fields, you can save changes, download the filled form, print it, or share it as necessary.

Complete your documents online by following these guidelines.