Progesterone and Estradiol Medication Shortage Form

Need help finding estradiol patches, progesterone capsules, or another hormone medication?

We understand how frustrating it can be when your medication is difficult to find. Skippack Pharmacy may be able to help.

Through this form, we’ll ask a few questions about your medication and contact information so our team can review your situation and follow up with next steps.

If your prescription is currently at another pharmacy, we may be able to help transfer it. If not, we can guide you on having your prescriber send a new prescription to us.

Important: Please do not have your prescriber send a prescription to us until we confirm we have it in stock and can fill it for you.

***If you already receive hormonal products from Skippack pharmacy, we do not need you to fill out this form again. We just need this form filled out once please.***

Patient Status with Skippack Pharmacy*

I am currently a Skippack Pharmacy patient for prescriptionsI am currently a Skippack Pharmacy patient for vaccinesI am new to Skippack Pharmacy

Who is filling out this form?*

I am filling this out for myselfI am filling this out for my spouse, significant other, family memberI am filling this out for my patient

Patient's Name*

First NameLast Name

Date of Birth*

MonthDayYear

Patient Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Cell Phone Number*

Area CodePhone Number

Email*

Please double check and ensure this is accurate

Please list the name and city of your CURRENT PHARMACY*

Please list the name and city of the DOCTOR/PROVIDER who prescribes this medication for you *

Select the name(s) of the hormonal medication(s) you take.*

Estradiol patch (once weekly) - GENERIC estradiol transdermal system once weekly (4 patches per month)Estradiol patch (twice weekly) - GENERIC estradiol transdermal system twice weekly (8 patches per month)Progesterone capsule - GENERIC progesteroneEstradiol tablet (oral) - GENERIC estradiol tablets;Estradiol + norethindrone tablet (oral)- GENERIC estradiol/norethindrone acetate tabletsEstradiol vaginal cream - GENERIC estradiol vaginal cream 0.01%Estradiol vaginal insert/tablet- GENERIC estradiol vaginal inserts/tabletsEstradiol topical gel/spray - GENERIC estradiol gel 0.1%Other

We know some patients may be on multiple medications (i.e. patch and capsules) thus have a spot below you can put the information for them (if applicable)

What strength of medication 1 do you take?*

How many tablets, capsules, or patches do you receive each month for medication 1?*

If applicable, what strength of medication 2 do you take?

If applicable, how many tablets, capsules, or patches do you receive each month for medication 2?

Any other information you would like to add?

Please input the numbers/letters from your Prescription Insurance card. You are looking at your prescription card if it has the letters RX on it otherwise, you are likely looking at your medical card. If you can't find the information or will pay out of pocket, can skip this question.

I confirm that I have a valid prescription for hormonal therapy and will not use this information for any other purpose. I understand and acknowledge that I will have my prescriber send a script to Skippack Pharmacy only if I am informed to do so. I understand and acknowledge that Skippack Pharmacy is trying their best to serve the community and this shortage; however, a special team handles these requests thus a call to the pharmacy will not expedite the process. I will be informed via email of next steps.*

Estradiol Patches and Progesterone Medication Shortages