Medication Order Request Form
Please complete this form to communicate your request for medication. Once your request is received, an Ivira team member will reach out to you within (1) business day to confirm and schedule your order. Please allow 2 business days for processing and 1 business day for shipping. Keep in mind, this form is not a guarantee of service. Not to worry! Access is our top priority! Ivira Specialty will inform you of any challenges of servicing your request and will work quickly to find the answers you need.
New or Existing Patient
*
Existing Patient
New Patient
How would you like to send the information
Manually
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Patient Name
*
First Name Last Name
Patient DOB
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-
Month
-
Day
Year
Date
Patient 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
Patient Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Insurance Information
*
Rows
Information
Insurance Name
Member ID
Group ID
Plan Type (PPO, HMO, EPO, POS)
Or attach face sheet
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Copy of Rx
*
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& Copies of Insurance Cards
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Prescriber Name
*
First Name
Last Name
Prescriber DEA
*
Medication
*
Please Select
Abilify Asimtufii 720 Mg/2.4 Ml
Abilify Asimtufii 960 Mg/3.2 Ml
Abilify Maintena Er 300 Mg Syr
Abilify Maintena Er 300 Mg Vl
Abilify Maintena Er 400 Mg Syr
Abilify Maintena Er 400 Mg Vl
Aristada Er 1,064 Mg/3.9 Ml Syr
Aristada Er 441 Mg/1.6 Ml Syrn
Aristada Er 662 Mg/2.4 Ml Syrn
Aristada Er 882 Mg/3.2 Ml Syrn
Aristada Initio Er 675 Mg/2.4
Botox 100 Unit Vial
Botox 200 Unit Vial
Botox Cosmetic 100 Unit Vial
Botox Cosmetic 50 Unit Vial
Brixadi Monthly 128 Mg/0.36 Ml Syringe
Brixadi Monthly 64 Mg/0.18 Ml Syringe
Brixadi Monthly 96 Mg/0.27 Ml Syringe
Brixadi Weekly 24 Mg/0.48 Ml Syringe
Brixadi Weekly 32 Mg/0.64 Ml Syringe
Brixadi Weekly 8 Mg/0.16 Ml Syringe
Invega Hafyera 1,092 Mg/3.5 Ml
Invega Hafyera 1,560 Mg/5 Ml
Invega Sustenna 117 Mg/0.75 Ml
Invega Sustenna 156 Mg/ml Syrg
Invega Sustenna 234 Mg/1.5 Ml
Invega Sustenna 39 Mg/0.25 Ml
Invega Sustenna 78 Mg/0.5 Ml
Invega Trinza 273 Mg/0.88 Ml
Invega Trinza 410 Mg/1.315 Ml
Invega Trinza 546 Mg/1.75 Ml
Invega Trinza 819 Mg/2.63 Ml
Liletta 52 Mg System
Lupron Depot 11.25 Mg 3mo Kit
Lupron Depot-Ped 11.25 Mg 3mo Kit
Mirena 52 Mg System
Paragard T 380-A Iud
Risperdal Consta 12.5 Mg Syr
Risperdal Consta 12.5 Mg Vial
Risperdal Consta 25 Mg Syr
Risperdal Consta 25 Mg Vial
Risperdal Consta 37.5 Mg Syr
Risperdal Consta 37.5 Mg Vial
Risperdal Consta 50 Mg Syr
Risperdal Consta 50 Mg Vial
Spravato 28 Mg Nasal Spray
Spravato 56 Mg Dose Pack
Spravato 84 Mg Dose Pack
Sublocade 100 Mg/0.5 Ml Syring
Sublocade 300 Mg/1.5 Ml Syring
Vivitrol 380 Mg Vial + Diluent
Zyprexa Relprevv 210 Mg Vial
Zyprexa Relprevv 210 Mg Vl Kit
Zyprexa Relprevv 300 Mg Vial
Zyprexa Relprevv 300 Mg Vl Kit
Zyprexa Relprevv 405 Mg Vial
Zyprexa Relprevv 405 Mg Vl Kit
Refills
*
Appointment Date
*
-
Month
-
Day
Year
Date
Requested Delivery Date
*
-
Month
-
Day
Year
Date
Ship To Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Contact Person Name
*
First Name
Last Name
Preferred Method of Communication
*
Email
Phone
Secure SMS
Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Cell Phone Number (secure SMS)
Please enter a valid phone number.
Format: (000) 000-0000.
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