Rx For Custom Compounding Only
Description: Sodium Fluoride Gel
Amount: ________ ml
Refills: ______
Date of prescription: ___________________
Dentist or doctor name: _________________
Dentist or doctor phone: ________________
Dentist DEA number: ___________________
Patient name: _________________________
Patient address: _______________________
_____________________________________
_____________________________________
Patient phone number: __________________
Formula:
(Measurements by weight)
- Sodium Fluoride 1.1%
- Sodium Phosphate 1.2%
- Sodium Methylcellulose 2%
- Pure, Sterile Water 95.7%
- No additional ingredients or substitutions
(no flavor, no sweetener, no preservatives).
KEEP REFRIGERATED