Trimix Prescription Submission Form Please complete all required fields! Name: (*) Invalid Input Address: (*) Invalid Input City: (*) Invalid Input Zip Code: (*) Invalid Input Exp: (*) Invalid Input DOB (MM/DD/YYYY) (*) Invalid Input Phone: (*) Invalid Input STATE: (*) AlabamaAlaskaArizonaArkansasCalifornia ColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomin Invalid Input Credit Card Number: (*) Invalid Input VC: (*) Invalid Input Prescription: At least one of the following items should be selected. Papaverine 30mg/ml Phentolamine 1mg/ml Papaverint 30mg/ml Phentolamine 1mg/ml PGE 10mcg/ml Papverin 30mg/ml Phentolamone 2mg/ml PGE 20mcg/ml 5ml10ml Please select one 5ml10ml Please select one! 5ml10ml Please select one! Quatro-Mi Tri-Mix Custom Papaverine 30mg/ml Phentolamine 1mg/ml PGE 10mcg/ml Atropin 0.15mg/ml Papaverine mg/ml Invalid Input Phentolamine mg/ml Invalid Input PGE mcg/ml Invalid Input 5ml10ml Please select one! 5ml10ml Please select one! Syringes 1ml X 30G X 1/2 inch5ml10mlOther Invalid Input Please select one
