Lidocainum basicum 3,50 g — 11.67%, Tetracaini hydrochloridum 3,50 g — 11.67%, Alcoholus cetearylicus 2,00 g — 6.67%, Propylenglycol 2,50 g — 8.33%, Polysorbatum 80 0,15 g — 0.500%, Phenoxyethanolum 0,40 g — 1.33%, Aqua purificata q.s. ad 30,00 g — q.s.