Pharmacy Supply Order Form

ALL orders MUST be requested and signed for by a PIC or Pharmacy Technician whose name has been previously submitted and approved by ODEMSA. For security purposes, orders submitted without the approved name and signature WILL NOT be processed.
We strongly recommend that you ensure your order quantities are sufficient to cover your pharmacy's needs for a minimum of three (3) months.
We appreciate your patience as it may take up to one (1) week for your request(s) to be fulfilled.
We are pleased to announce that our ordering system has been improved to include automated notifications at different stages of your order. You will receive automated messages confirming the receipt of your order, providing updates on its processing, and notifying you when it has been shipped or delivered.
We kindly ask that all future requests for supplies be submitted through this system.
The "ALS Drug Kit Contents Sheet & Schematic" and the "Drug Kit Discrepancy Form" are now conveniently available online under the "Pharmacy" section of the page linked below.

odemsa.net/regional-documents/

Name*

First NameLast Name

What Facility Are You Ordering For? *

Email*

example@example.com

Phone Number*

Pharmacy Shipping Address*

Street Address

Department/ Suite# / Room# / etc.

CityState / Province

Postal / Zip Code

What item(s) do you require?

Drug Kit Seals - Yellow (Old Style/Flat)

Seals come in bags of 100. For tracking please enter the actual number of seals and not the number of bags.

Drug Kit Seals - Yellow (Total Seals Requesting, NOT sets)*

Seals set of 10. For tracking please enter the actual number of seals and not the number of sets.

Drug Kit Seals - Yellow (New Style/Round)

Seals set of 10. For tracking please enter the actual number of seals and not the number of sets.

Narcotics Drug Kit Seals - Red (Total Seals Requesting, NOT sets)*

Seals come in bags of 100. For tracking please enter the actual number of seals and not the number of bags.

Narcotics Drug Kit Seals - Red

Seals come in bags of 100. For tracking please enter the actual number of seals and not the number of bags.

Drug Kit Exchange Forms*

Drug Kit Exchange forms are not bundled, so enter the total number you require.

Drug Kit Discrepancy Forms

Medication Alert Card Template

ALS Drug Kit Contents Sheet & Schematic

By signing below, I, {name}, attest that I have been authorized by the Old Dominion EMS Alliance (ODEMSA) as a PIC or Pharmacy Technician to submit orders on behalf of {typeA7}. I certify that all information I have provided on and in connection with this form is true and correct to the best of my knowledge.

Signature*

Clear

What item(s) do you need?*

	Quantity Needed
ODEMSA ALS Drug Kit Seals - Yellow
ODEMSA ALS Drug Kit Seals - Red
Drug Kit Exchange Forms
Drug Kit Discrepancy Forms
Medication Alert Card Template
ALS Drug Kit Contents Sheet & Schematic

How do you like this form?

Fulfillment Date

Date

Pharmacy Supply Request

What item(s) do you require?

Attestation for Authorized Submission of Orders