Substance Use Disorder Delivery Request Form

SUBSTANCE ABUSE DISORDER DELIVERY REQUEST FORM

Altruix Trevose Specialty Pharmacy | 3800 Horizon Blvd, STE 103, Trevose PA, 19053
THIS FORM IS OPTIONAL.

You can also request delivery via email (sublocadetrevose@altruix.com), fax (215-357-2129), or phone (800-927-6703).
Medication Delivery Address *
City *
State *
Zip Code *
Preferred Phone # *
Please enter a valid phone number.
Fax #
Please enter a valid fax number.
Email
Enter email to receive confirmation of this submission
Prescriber Name *
As Shown on Prescription
Prescriber DEA# *
After Filling Out The Information For One Patient, You will Have The Option to Add An Additional Patient (Up To 10!)
1 Patient Name *
1 Patient DOB *

MonthDayYear
Date
1 Medication Dose *
1 Delivery Date Requested *

MonthDayYear
Date
1 Scheduled Injection Date - If Known

MonthDayYear
Date
1 Alternate prescriber (if diff from above listed prescriber)

alt. prescriberalt. DEA#
2 Patient Name
2 Patient DOB

MonthDayYear
Date
2 Medication Dose
2 Delivery Date Requested

MonthDayYear
Date
2 Scheduled Injection Date - If Known

MonthDayYear
Date
2 Alternate prescriber (if diff from above listed prescriber)

alt. prescriberalt. DEA#
3 Patient Name
3 Patient DOB

MonthDayYear
Date
3 Medication Dose
3 Delivery Date Requested

MonthDayYear
Date
3 Scheduled Injection Date - If Known

MonthDayYear
Date
3 Alternate prescriber (if diff from above listed prescriber)

alt. prescriberalt. DEA#
4 Patient Name
4 Patient DOB

MonthDayYear
Date
4 Medication Dose
4 Delivery Date Requested

MonthDayYear
Date
4 Scheduled Injection Date - If Known

MonthDayYear
Date
4 Alternate prescriber (if diff from above listed prescriber)

alt. prescriberalt. DEA#
5 Patient Name
5 Patient DOB

MonthDayYear
Date
5 Medication Dose
5 Delivery Date Requested

MonthDayYear
Date
5 Scheduled Injection Date - If Known

MonthDayYear
Date
5 Alternate prescriber (if diff from above listed prescriber)

alt. prescriberalt. DEA#
6 Patient Name
6 Patient DOB

MonthDayYear
Date
6 Medication Dose
6 Delivery Date Requested

MonthDayYear
Date
6 Scheduled Injection Date - If Known

MonthDayYear
Date
6 Alternate prescriber (if diff from above listed prescriber)

alt. prescriberalt. DEA#
7 Patient Name
7 Patient DOB

MonthDayYear
Date
7 Medication Dose
7 Delivery Date Requested

MonthDayYear
Date
7 Scheduled Injection Date - If Known

MonthDayYear
Date
7 Alternate prescriber (if diff from above listed prescriber)

alt. prescriberalt. DEA#
8 Patient Name
8 Patient DOB

MonthDayYear
Date
8 Medication Dose
8 Delivery Date Requested

MonthDayYear
Date
8 Scheduled Injection Date - If Known

MonthDayYear
Date
8 Alternate prescriber (if diff from above listed prescriber)

alt. prescriberalt. DEA#
9 Patient Name
9 Patient DOB

MonthDayYear
Date
9 Medication Dose
9 Delivery Date Requested

MonthDayYear
Date
9 Scheduled Injection Date - If Known

MonthDayYear
Date
9 Alternate prescriber (if diff from above listed prescriber)

alt. prescriberalt. DEA#
10 Patient Name
10 Patient DOB

MonthDayYear
Date
10 Medication Dose
10 Delivery Date Requested

MonthDayYear
Date
10 Scheduled Injection Date - If Known

MonthDayYear
Date
10 Alternate prescriber (if diff from above listed prescriber)

alt. prescriberalt. DEA#
Additional Notes:
In accordance with the Sublocade and Brixadi REMS Program, this medication will only be used in the healthcare office in which it is being delivered to and will not be transported to any other location, office, person, or given directly to the patient.
Requested by Name/Title *
Date Requested:

MonthDayYear
Today's Date
Should be Empty:

SUBSTANCE ABUSE DISORDER DELIVERY REQUEST FORM