Pharmacy Plaintiff Intake
Did a pharmacy deny you a prescription for medication your doctor prescribed you for treatment of COVID-19? Are you a physician who wrote a prescription for medication to treat COVID-19 that was denied by a pharmacy? Are you a pharmacist that has been prohibited (or hassled) from filling a prescription for medication to treat COVID-19 by corporate policies? If you fit one of these three criteria and would like to join AFLDS as a plaintiff in a lawsuit at no cost to you, please provide us with the following information. (This information will be kept confidential unless you choose otherwise.)
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Location of Event
*
Zip Code
State of Event
*
Please Select
AL
AK
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
State
Which best describes your role in this event?
*
Patient
Patient Advocate/Caregiver
Pharmacist
Prescribing Practitioner
Your Prescription was refused by which Pharmacy?
*
CVS
Walgreens
Other
Do you have a copy of that policy or exchange?
Yes
No
At which Pharmacy were you working when this event occurred?
Reason you were unable to fill prescription?
*
Corp. Policy
Other
Do you have a copy of that policy or exchange?
Yes
No
Which best describes this situation?
*
I am discouraged from writing prescriptions for COVID 19 therapeutics.
Prescription written for patient was denied.
Discouraged by:
Hospital or SNF or Assisted Living Policy
PPO, HMO, Insurance Policy
Peer Physician or Employer Physician/Group
Name of Medical Group, Organization or Facility
Prescription denied by:
CVS
Walgreens
Other Pharmacy
Hospital
SNF or Assisted Living Facility
Name of Medical Group, Organization or Facility
Do you have a copy of that policy or exchange?
Yes
No
Medication Prescribed:
Ivermectin
Hydroxychloroquine
Other
Do you have a copy of the prescription (if applicable):
*
Yes
No
Date of Prescription (if applicable):
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
You understand that you are submitting personal information related to your health that may be used in legal cases as a plaintiff. Your data will NEVER be shared, sold or rented.
*
I understand
Picture of Prescription:
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Policy or exchanges relevant to this event.
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Brief Summary:
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Should be Empty: