Vivitrol Enrollment Form
Form will be automatically sent to Sunray Specialty Pharmacy for processing. Please send an electronic prescription along with this form to avoid delays.
Patient's Name
*
First Name
Last Name
Patient's Date of Birth
*
-
Month
-
Day
Year
Date
If patient has Medicare, please include last 4 numbers of patient's social security number so that insurance information can be searched:
Patient's Gender
*
Please Select
Male
Female
Non-Binary
Prefer Not To Disclose
Patient's Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Patient's Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Patient's Height
*
Patient's Weight
*
Allergies to Medications
*
Concomitant Medications
*
Prescriber
*
When will the patient be returning to start therapy?
-
Month
-
Day
Year
Date
Where would you like the medication delivered?
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please upload pertinent office notes and LFTs (if available).
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