Bank's Apothecary Sublocade Delivery Request Form
This May NOT be used as a Prescription Order Form
Tel: 215-494 9403 Fax: 215 357 2129
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
Dosage Amount
N/A
100 Mg
300 Mg
Indicate if initiation dose
*
Yes
No
Patient’s Last Injection Date
*
-
Month
-
Day
Year
(or indicate if initiation dose)
Patient’s Scheduled Injection Date
*
-
Month
-
Day
Year
Date
Office Address Where Medication Is Being Delivered/Administered
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Name and title of contact person (for Sublocade)
*
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
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.
*
PLEASE INITIAL HERE
Clear
Doctor's Name
*
First Name
Last Name
Doctor’s DEA # (for above registered location)
*
Doctor’s XDEA number:
*
Submit
Should be Empty: