PRESCRIBER’S SIGNATURE DATE · Week 2 (Days 8-14) Week 3 (Days 15-21) Week 4 (Days 22-28) Week 5 (Days 29-35) Week 6 (Days 36-42) LDN 1.5 mg I Capsule Daily I Capsule Daily I Capsule

Low Dose Naltrexone Order Form

ACHC Accredited Pharmacy Toll-Free Phone 888-290-2244

Direct Phone 201-447-2020 Direct Fax 201-447-3253

[email protected]

PRESCRIBER’S SIGNATURE DATE

Low Dose Naltrexone Titration Starter Kit

1. _______ #1 LDN Starter Kit=(Naltrexone 1.5mg Capsule #63 & Naltrexone 0.5mg Capsule #42) SIG: Take capsules daily prior to bedtime as per starter kit directions

2. _______ Naltrexone (LDN) 0.5 mg Capsule Quantity: 70 (1st month supply) SIG: Start at 1 capsule (0.5 mg) at bedtime and titrate up each week by 1 capsule (0.5 mg) to desired effect or physician specified dose

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Patient’s Name: Prescriber’s Name:

Patient Drug Allergies: Street Address:

Street Address: City, State ZIP:

City, State ZIP: Office #:

Date of Birth: Fax #:

Phone (CELL) #: Email:

Email:

3. _______ Naltrexone (LDN) 0.1 mg Capsule Quantity: 70 (1st month supply) SIG: Start at 1 capsule (0.1 mg) at bedtime and titrate up each week by 1 capsule (0.1 mg) to desired effect or physician specified dose

4. _______ Maintenance Dose: Naltrexone (LDN) 0.1 – 4.5 mg Capsule Quantity: _______________ SIG: Take 1 capsule daily at bedtime or as directed by physician

5. _______ Naltrexone 3% Transdermal Cream Quantity: 30 grams SIG: Apply 4 clicks 3 to 4 times a day to painful areas

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