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NUTRITIONAL PRESCRIPTION
Patient Details:
Name of Patient:
Name of Patient
First Name:
Last Name:
IC/Passport Number:
Date of Birth:
Contact Number:
Address:
Line 1:
Line 2:
City:
Country:
Singapore
State:
Singapore - No State
Postal Code:
Prescription Details:
Preferred Dosage:
Powder
Capsules
Preferred Dosage
Vegetarian:
Yes
No
Vegetarian
Duration of Supply:
Number of Repeats:
:
All does expressed in Elemental Values
Ingredients:
Alpha Lipoic Acid (mg)
Ascorbic acid [Vitamin C] (mg)
Beta Carotene (IU)
Biotin (mcg)
Calcium (mg) as Carbonate
Calcium (mg) as Citrate
Chromium (mcg) as Picolinate
Coenzyme Q10 (mg)
Copper (mg) as Gluconate
Folic acid (mcg)
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Compounding Helpline
(For Healthcare Professionals)
+65 9359 2132
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