Vivitrol Delivery Request Form

We have updated this form to make it easier for you to submit delivery requests.

Questions? Call 1-800-927-6703.
VIVITROL DELIVERY REQUEST FORM

Altruix Trevose Specialty Pharmacy | 3800 Horizon Blvd, STE 103, Trevose PA, 19053
For new patient delivery requests, please send a prescription to our pharmacy via escribe, fax (215-357-2129), or phone (800-927-6703) along with this form.

If your office would like deliveries to multiple locations, please complete a separate form for each location.
Healthcare Practice's Address Where Medication is Being Delivered To *
Preferred Phone #*
Please enter a valid phone number.
Fax #
Please enter a valid fax number.
Email
Enter email to receive confirmation of this submission
After Filling Out The Information For One Patient, You will Have The Option to Add An Additional Patient (Up To 5!)
Patient Name 1*
Patient DOB*

MonthDayYear
Date
Medication Dose*
Delivery Date Scheduled*

MonthDayYear
Date
Patient Name 2
Patient DOB 2

MonthDayYear
Date
Medication Dose 2
Delivery Date Scheduled 2

MonthDayYear
Date
Patient Name 3
Patient DOB 3

MonthDayYear
Date
Medication Dose 3
Delivery Date Scheduled 3

MonthDayYear
Date
Patient Name 4
Patient DOB 4

MonthDayYear
Date
Medication Dose 4
Delivery Date Scheduled 4

MonthDayYear
Date
Patient Name 5
Patient DOB 5

MonthDayYear
Date
Medication Dose 5
Delivery Date Scheduled 5

MonthDayYear
Date
Additional Notes:
Requested by Name/Title*
Date Requested

MonthDayYear
Today's Date
Should be Empty:

We have updated this form to make it easier for you to submit delivery requests.