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. 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.
Patient Name
First Name Last Name
Patient DOB
-
Month
-
Day
Year
Date
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
Appointment or Needs by Date
-
Month
-
Day
Year
Date
Requested Delivery Date
-
Month
-
Day
Year
Date
Contact Person Name
First Name
Last Name
Contact Phone Number
Please enter a valid phone number.
Email
example@example.com
Ship To Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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