Clone of Substance Use Disorder Delivery Request Form

SUBSTANCE USE DISORDER DELIVERY REQUEST FORM

Altruix Huntingdon Pharmacy | 620 Washington Street, Suite 110, Huntingdon PA, 16652
THIS FORM IS OPTIONAL.

You can also request delivery via fax (814-996-2830), or phone (814-996-2838).
Medication Delivery Address
City
State
Zip Code
Preferred Phone #
Please enter a valid phone number.Format: (000) 000-0000.
Fax #
Please enter a valid fax number.Format: (000) 000-0000.
Email
Enter email to receive confirmation of this submission
Prescriber Name
As Shown on Prescription
Prescriber DEA#
After Filling Out The Information For One Patient, You will Have The Option to Add An Additional Patient (Up To 10!)
1 Patient Name
1 Patient DOB

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
1 Medication Dose
1 Delivery Date Requested

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
1 Scheduled Injection Date - If Known

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
1 Alternate prescriber (if diff from above listed prescriber)

alt. prescriberalt. DEA#
2 Patient Name
2 Patient DOB

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
2 Medication Dose
2 Delivery Date Requested

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
2 Scheduled Injection Date - If Known

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
2 Alternate prescriber (if diff from above listed prescriber)

alt. prescriberalt. DEA#
3 Patient Name
3 Patient DOB

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
3 Medication Dose
3 Delivery Date Requested

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
3 Scheduled Injection Date - If Known

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
3 Alternate prescriber (if diff from above listed prescriber)

alt. prescriberalt. DEA#
4 Patient Name
4 Patient DOB

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
4 Medication Dose
4 Delivery Date Requested

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
4 Scheduled Injection Date - If Known

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
4 Alternate prescriber (if diff from above listed prescriber)

alt. prescriberalt. DEA#
5 Patient Name
5 Patient DOB

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
5 Medication Dose
5 Delivery Date Requested

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
5 Scheduled Injection Date - If Known

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
5 Alternate prescriber (if diff from above listed prescriber)

alt. prescriberalt. DEA#
6 Patient Name
6 Patient DOB

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
6 Medication Dose
6 Delivery Date Requested

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
6 Scheduled Injection Date - If Known

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
6 Alternate prescriber (if diff from above listed prescriber)

alt. prescriberalt. DEA#
7 Patient Name
7 Patient DOB

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
7 Medication Dose
7 Delivery Date Requested

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
7 Scheduled Injection Date - If Known

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
7 Alternate prescriber (if diff from above listed prescriber)

alt. prescriberalt. DEA#
8 Patient Name
8 Patient DOB

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
8 Medication Dose
8 Delivery Date Requested

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
8 Scheduled Injection Date - If Known

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
8 Alternate prescriber (if diff from above listed prescriber)

alt. prescriberalt. DEA#
9 Patient Name
9 Patient DOB

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
9 Medication Dose
9 Delivery Date Requested

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
9 Scheduled Injection Date - If Known

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
9 Alternate prescriber (if diff from above listed prescriber)

alt. prescriberalt. DEA#
10 Patient Name
10 Patient DOB

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
10 Medication Dose
10 Delivery Date Requested

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
10 Scheduled Injection Date - If Known

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
10 Alternate prescriber (if diff from above listed prescriber)

alt. prescriberalt. DEA#
Additional Notes:
In accordance with the Sublocade and Brixadi REMS Program, this medication will only be used in the healthcare office in which it is being delivered to and will not be transported to any other location, office, person, or given directly to the patient.
Requested by Name/Title
Date Requested:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearToday's Date
Should be Empty:

SUBSTANCE USE DISORDER DELIVERY REQUEST FORM