Place an Order

Place an Order Page

To place an order for Endura-KT, please complete the order form below and select the “Submit” tab on the lower left side of the order form.

Once Ventis Pharma receives your request, we will confirm receipt of your order.

You can also fax this form to Ventis Pharma (800-441-5841) or you can scan and email the order form to (ventis.orders@nubratorirx.com).

If you prefer, you can always provide your completed order form to your Ventis Pharma sales representative.

Please contact us at Ventis Pharma if you have any questions (800-537-0857).

381 Van Ness Ave Suite 1507, 1508 Torrance, CA 90501

FAX REQUEST TO 800-537-0857 OR EMAIL To: ventis.orders@nubratorirx.com

Pharmacy Name:

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Sterile Injections
Product	Package Size	Qty
0.4% Lidocaine HCl with 0.2% Tetracaine HCl Injection 200mg/100mg/50mL (4mg/2mg/mL)	50 mL vial
Epinephrine Injection 0.2mg/0.2mL (1mg/mL)	0.2 mL syringe

Packaging

Individual Units

Provide Alcohol Pad, Transfer Needle and Stickers (Kit)

Note: if selection is not made, order will ship with kit

Shipping

Please indicate shipping Method

Standard Overnight(4:30pm)

Priority Overnight(10:30am)

First Overnight(8am)

Bill to FedEX Account:

Add Shipping to invoice

Note: If selection is not made, order will ship standard Overnight, and shipping will be added to invoice

Signature of Authorized Agent

Print Name of Authorized Agent

Date

I am a representative of this pharmacy and am responsible for the submission of this order, I authorize Nubratori Rx to ship all items listed above. The pharmacy agrees that any changes between the Outsourcing Facility compounded drug and a comparable approved drug will be administered or dispensed only to a patient for whom the change will help to make a clinical difference, as determined by the practitioner or a person able to make that representation on the practitioner’s behalf. The pharmacy further agrees to maintain documentation sufficient to demonstrate that the compounded preparation is prescribed and dispensed to such patients, by maintaining notation on the prescription form

Place an Order Page

FAX REQUEST TO 800-537-0857 OR EMAIL To: ventis.orders@nubratorirx.com

Contact information: