Prescriber Sublocade Preferences

Prescriber Sublocade Preferences

Please fill out this form prior to prescribing Sublocade for pharmacy administration for the first time. This form can be completed again if any of these responses change in the future.
Prescriber's Name*

First NameLast Name
Prescriber's DEA *
Would you like the pharmacist to administer lidocaine prior to each Sublocade injection?*
Please send a lidocaine prescription along with each Sublocade prescription to Sunray Drugs Specialty. We recommend to write refills as needed, to ensure the patient receives pre-medication with each injection.
If your patient reports having used opioids within 2 days (48 hours) of the scheduled injection, do you want your patient to receive Sublocade?*
Other, please specify (i.e. prefer different time frame, call the office, etc.)*
Would you like for your patient to receive naloxone with the injection?*
If your patient misses their scheduled appointment at the pharmacy, up to how many days after the due date can the pharmacist administer Sublocade?*
How would you prefer the injection confirmation be sent to you/your office?*
You may select multiple options if desired.
Please enter your preferred fax number*
Please enter a valid phone number.
Please enter your preferred email*
example@example.com
Please enter your preferred phone number*
Please enter a valid phone number.
Please specify how you would like injection confirmations communicated*
Should be Empty:

Please send a lidocaine prescription along with each Sublocade prescription to Sunray Drugs Specialty. We recommend to write refills as needed, to ensure the patient receives pre-medication with each injection.