MANUS SOLIS · Compounding Prescription
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Compounding Prescription
Ordonnance de préparation magistrale
To: Trutina Pharmacy · Attn: Donna Kingman
Fax: 1-866-418-9343
Date: 
Prescriber Prescripteur
Dr. Handsun Xiao
MD, CCFP · CPSO #284371 · CMQ #03474
2300 Yonge Street, Suite 1600 · Toronto, ON M4P 1E4 Tel +1 (514) 677-9426 · Fax +1 (844) 616-0019 handsun@manussolis.ca · manussolis.ca
Patient Patient(e)
Name Nom
DOB DDN Sex
HCN N° carte santé
Address
Tel Email
Allergies
Main Hormones — Page 1
Hormones principales — Page 1 · Check ☐ to select
Estradiol (E2)
Œstradiol
Cream Crème · 1 gm = 2 pumps
0.25 mg/gm 0.5 mg/gm 0.75 mg/gm 1.0 mg/gm
Oral Capsule Capsule orale
1.5 mg 1.75 mg 2.0 mg
Sig
Qty
Refills
Estriol (E3)
Œstriol
Vaginal Cream Crème vaginale
0.5 mg/gm 1.0 mg/gm 2.0 mg/gm
Vaginal Suppository Suppositoire vaginal
0.5 mg 1.0 mg 2.0 mg
Custom Facial Cream Crème visage · 2–3 × / wk
3 mg/gm 4 mg/gm
Sig
Qty
Refills
BiEst  (E2 20 % : E3 80 %)
BiEst
Cream Crème · 1 gm = 2 pumps
0.5 mg/gm 1.0 mg/gm 1.25 mg/gm 2.0 mg/gm 2.5 mg/gm 3.75 mg/gm 5.0 mg/gm
Sig
Qty
Refills
Micronized Progesterone
Progestérone micronisée
SR Oral Capsule Capsule LP
25 mg 50 mg 75 mg 100 mg
IR Oral Capsule Capsule LI
25 mg 50 mg 75 mg 100 mg
Cream Crème
20 mg/gm 30 mg/gm 40 mg/gm
Suppository Suppositoire
25 mg 50 mg 75 mg 100 mg
SL Drop 100 mg/ml Gtte SL
25 mg 50 mg 75 mg 100 mg
Troche IR
25 mg 50 mg 75 mg 100 mg 200 mg
Sig
Qty
Refills
Testosterone (TRT)
Testostérone
Topical Cream Crème topique
0.1 mg/gm 0.5 mg/gm 1 mg/gm 5 mg/gm 10 mg/gm 50 mg/gm 100 mg/gm
Topical Gel Gel topique
10 mg/gm 25 mg/gm 50 mg/gm 75 mg/gm
Troche IR women only
Injection
Enanthate 200 mg/ml · 5 ml Cypionate 100 mg/ml · 10 ml
Total Qty Authorized
Qty Dispensed Each Time
Interval (days)
Refill # Days
Sig
DHEA
DHEA
Oral Capsule Capsule orale
5 mg 10 mg 15 mg 25 mg
SL Drops Gouttes SL
20 mg 25 mg
Troche IR
10 mg
Total Qty
Qty Dispensed
Interval Days
Sig
Thyroid
Thyroïde
Compounded T3 / T4 Capsule
15 mg 30 mg 60 mg 90 mg
T3/T4 Combo · Custom
ERFA  desiccated
30 mg 60 mg 125 mg
Synthroid  µg
25 50 75 88 100 112 125 137 150 175 200 300
Cytomel  µg
5 25
Sig
Qty
Refills
Pregnenolone
Prégnénolone
Oral Capsule
50 mg 100 mg
Custom Facial Cream
0.2 mg/gm 0.3 mg/gm 1 mg/gm 4 mg/gm
Sig
Qty
Refills
Tadalafil
Tadalafil
Capsule
4 mg 6 mg 7.5 mg 11 mg 15 mg 19 mg 22 mg 24 mg
Sig
Qty
Refills
LDN (Low-Dose Naltrexone)
Naltrexone faible dose
Capsule
0.5 mg 1.0 mg 1.5 mg 3.0 mg 3.5 mg 4.5 mg
SL Drops
10 mg/ml
Oral Suspension
2 mg/ml
Sig
Qty
Refills
HGH Injection  (somatropin)
Hormone de croissance · expires 28 days after priming
Norditropin® no assembly
10 mg / 2 ml
Omnitrope assembly required
5 mg / 1.5 ml 10 mg / 1.5 ml 15 mg / 1.5 ml
Qty Authorized
Qty Dispensed
Interval Days
Refill # Days
Sig
Clinical Notes Notes cliniques
Date
Prescriber Signature Signature du prescripteur
Dr. Handsun Xiao, MD, CCFP CPSO #284371 · CMQ #03474
Patient ID
QR
Jane ID
License on Rx
Manus Solis
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