Get the free FAX TO: (888) 807-6643

Prescribing Clinician or Authorized Representative Signature Created 03/17 Reviewed/Revised 03/21/2017 Date 4/13/2017 4 09 PM. Drug Name Last Fill Date Details If no Is there rationale for not using a topical corticosteroid No 4. Please indicate diagnosis atopic dermatitis i.e. eczema Other 2. Has the patient tried and failed therapy or does the patient have a contraindication to at least two medium to high potency topical corticosteroid Yes If yes please provide details. Eucrisa crisaborole...

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