Bank's Apothecary Sublocade Delivery Request Form

Bank's Apothecary Sublocade Delivery Request Form

This May NOT be used as a Prescription Order Form
Any questions please call 267-921-0921.

Medication Will Not Be Sent Unless All Lines Have Been Completed
Today's Date *

Month Day Year
Date
Patient Name *

First Name Last Name
Patient DOB *

Month Day Year
Date
Patient’s Phone # *

Area Code Phone Number
Dose Type *

Loading Maintenance
Last Loading Dose Injection Date

Month Day Year
Enter date if applicable
Dosage Amount *
Patient’s Last Injection Date

Month Day Year
(or indicate if initiation dose)
Patient’s Last Injection Date *

Month Day Year
(or indicate if initiation dose)
Patient’s Scheduled Injection Date *

Month Day Year
Date
Medication Delivery Date Selection

Month Day Year
Date
Office Address Where Medication Is Being Delivered/Administered *

Street Address

Street Address Line 2

City State

Postal / Zip Code
Name and title of contact person (for Sublocade) *

First Name Last Name
In accordance with the Sublocade REMS Program, I attest that this medication will ONLY be used in this office and will NOT be transported to any other location/office/person or given to the patient. Typing your name here will act as your digital signature. *

First Name Last Name
Phone # of Contact Person *

Area Code Phone Number
Fax #

Area Code Phone Number
Email Address of Contact Person (optional)
example@example.com
Doctor's Name *

First Name Last Name
Doctor’s DEA # (for above registered location) *
Doctor’s XDEA number: *
Notes

0/250
Should be Empty: