Give this to your dentist or doctor:
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)
KEEP REFRIGERATED

Patient Notice:

Be sure to read the separate instructions for use.