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Get Leiter's Compounding Order Form -C PF Solution 2015-2023

Ystaff@ leiterrx.com OK to compound 0.2mg/ml (0.02%) 1 ml vial 0.3mg/ml (0.03%) 1 ml vial 0.4mg/ml (0.04%) 1 ml vial • Supplier to major HMO groups, research hospitals and clinical drug trials • 24 hour turnaround • Free overnight shipment for orders over $500 Fax #: Prescribers Full Name: NPI#/DEA# Faxed By: Date Ordered/Faxed: (If your state does not allow office use compounding, please attach patient prescriptions.) Shipping and Billing Inf.

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