Injectable Drug Delivery Request Form
Please contact us for any special requests
Facility Name
*
Patient Name
*
Patient Date of Birth
*
-
Month
-
Day
Year
Date
Initial Induction
Please Select
Yes
No
(If available)
Date of Last Dose
-
Month
-
Day
Year
(If maintenance)
Requested Delivery Date
*
-
Month
-
Day
Year
Date
Drug
Sublocade
Brixadi
Vivitrol
Loading Dose
Please Select
Brixadi 64mg
Brixadi 96mg
Brixadi 128mg
Sublocade 300mg
Sublocade 100mg
Vivitrol 380mg
(If available)
Maintenance Dose
*
Please Select
Brixadi 64mg
Brixadi 96mg
Brixadi 128mg
Sublocade 300mg
Sublocade 100mg
Vivitrol 380mg
Facility Contact
*
First Name
Last Name
Email
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Submit
Should be Empty: