Buprenorphine ER Delivery Request
If you need delivery same day, please contact the pharmacy directly at (215)471-4000x0. By completing this form, you agree that you will not transfer, sell, or distribute Sublocade or Brixadi. You attest that this medication will only be used in the office specified and will not be transported to any other location, office, or person or given directly to the patient.
Patient's Name
*
First Name
Last Name
Patient's Date of Birth
*
-
Month
-
Day
Year
Date
Is patient new to Sunray Drugs Specialty?
*
Please Select
Yes
No
Does patient have any allergies to medications?
*
Please Select
Yes
No
Select patient's drug allergies
*
Penicillins
Sulfa
NSAIDs
Iodine
Other
Patient Concomitant Medications (include medication name, dose, and directions)
*
Medication Requested
*
Please Select
Brixadi 8mg
Brixadi 16mg
Brixadi 24mg
Brixadi 32mg
Brixadi 64mg
Brixadi 96mg
Brixadi 128mg
Sublocade 100mg
Sublocade 300mg
Is this to be administered at the office or a Sunray Drugs pharmacy location?
*
Please Select
Office
Pharmacy
Patient's Scheduled Injection Date (if known)
-
Month
-
Day
Year
Date
Requested Delivery Date
*
-
Month
-
Day
Year
Date
Administering Provider's Name
*
Administering Provider's DEA Number
*
Delivery Address Line 1
*
Street Address
Delivery Address Line 2
Suite, Floor, etc.
City
*
State
*
Zip Code
*
Patient ID (optional)
Additional Notes (optional)
Please enter your email if you would like a confirmation that the request was received.
example@example.com
Submit
Should be Empty: