Penile Injection (Trimix / Bimix) Intake Form Template
Intracavernosal injection therapy using Trimix (alprostadil, phentolamine, papaverine), Bimix, or similar compounded formulations is an effective treatment for erectile dysfunction, particularly in patients who do not respond to oral PDE5 inhibitors. This intake form documents erectile dysfunction symptoms, prior injection therapy history, and screens for contraindications including priapism risk, hematologic conditions, anatomical abnormalities, and conflicting medications.
Free Template
Penile Injection (Trimix / Bimix) Intake Form
Form Preview
This is how the form appears to patients. Customize with your practice name and branding.
Your Practice Name
Penile Injection (Trimix / Bimix) Intake Form
1 General Patient Information
Please provide your personal information.
General Patient Information
Please provide your personal information.
First Name
Jane
Last Name
Smith
Date of Birth
—
Can you confirm you are 18 years or older?
Height
e.g. 5'8"
Weight
e.g. 170 lbs
2 Medical History
Please answer all questions as accurately as possible. Your provider will review this information.
Medical History
Please answer all questions as accurately as possible. Your provider will review this information.
Are you actively taking any medications? If so, please list them.
List all current medications, dosages, and frequencies
Do you have any medication allergies? If so, please list them.
List all known drug allergies and reactions
Are you currently being treated or have you been treated for any medical conditions? If so, please list them.
List all current and past medical conditions
Have you had any past surgeries? If so, please list them.
List all surgeries and approximate dates
What is/was your sex assigned at birth?
Male
Emergency contact name and phone number
Name — (555) 000-0000
Mailing address
123 Main St, City, State, ZIP
Any other questions or concerns?
Optional — share anything else you'd like your provider to know
3 Symptoms
Select all symptoms that currently apply to you.
Symptoms
Select all symptoms that currently apply to you.
4 Contraindications
Select all conditions that currently apply to you.
Contraindications
Select all conditions that currently apply to you.
5 Prior Treatment History
Please answer the following question about your treatment history.
Prior Treatment History
Please answer the following question about your treatment history.
Have you been prescribed penile injections before for erectile dysfunction?
Preview only. Your live form will include your branding and e-signature capture.
Compliance & Regulatory Notes
Review these notes before deploying this form in your practice.
Trimix and Bimix are compounded medications. Dispensing pharmacies must be licensed 503A or 503B facilities. Verify current licensure and certificate of analysis. See FDA: https://www.fda.gov/drugs/human-drug-compounding
Priapism is a serious risk. Patients must be counseled to seek immediate emergency care for erections lasting more than 3 hours and should have phenylephrine available.
MAO inhibitors are a contraindication due to risk of severe cardiovascular events when combined with sympathomimetic components. Review all current medications.
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Sources & References
Frequently Asked Questions
What is Trimix and how is it different from oral ED medications?
Trimix is a compounded intracavernosal injection containing alprostadil, phentolamine, and papaverine that directly relaxes penile smooth muscle to produce an erection. It is more potent than oral PDE5 inhibitors and is effective in patients who do not respond to oral therapy.
What should a patient do if priapism occurs?
Patients should seek emergency medical care immediately for any erection lasting more than 3-4 hours. Phenylephrine injection is the first-line treatment and patients should have it available at home per provider instructions.