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!)
Patient Name 1*
Patient DOB*

MonthDayYear
Date
Medication Dose*
Delivery Date Requested*

MonthDayYear
Date
Scheduled Injection Date - If Known

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

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

MonthDayYear
Date
Medication Dose 2
Delivery Date Requested 2

MonthDayYear
Date
Scheduled Injection Date 2 - If Known

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

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

MonthDayYear
Date
Medication Dose 3
Delivery Date Requested 3

MonthDayYear
Date
Scheduled Injection Date 3 - If Known

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

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

MonthDayYear
Date
Medication Dose 4
Delivery Date Requested 4

MonthDayYear
Date
Scheduled Injection Date 4 - If Known

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

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

MonthDayYear
Date
Medication Dose 5
Delivery Date Requested 5

MonthDayYear
Date
Scheduled Injection Date 5 - If Known

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

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

MonthDayYear
Date
Medication Dose 6
Delivery Date Requested 6

MonthDayYear
Date
Scheduled Injection Date 6 - If Known

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

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

MonthDayYear
Date
Medication Dose 7
Delivery Date Requested 7

MonthDayYear
Date
Scheduled Injection Date 7 - If Known

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

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

MonthDayYear
Date
Medication Dose 8
Delivery Date Requested 8

MonthDayYear
Date
Scheduled Injection Date 8 - If Known

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

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

MonthDayYear
Date
Medication Dose 9
Delivery Date Requested 9

MonthDayYear
Date
Scheduled Injection Date 9 - If Known

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

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

MonthDayYear
Date
Medication Dose 10
Delivery Date Requested 10

MonthDayYear
Date
Scheduled Injection Date 10 - If Known

MonthDayYear
Date
Alternate prescriber 10 (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