Progesterone and Estradiol Medication Shortage Form

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

We know how frustrating it can be when your medication is hard to find. Skippack Pharmacy may be able to help review availability and explain your options.

Please complete this form one time so our team can gather your medication, contact, insurance, and pharmacy information.

After you submit the form, our team will check availability and follow up with next steps.

In some cases, we may have the medication available and can help with a transfer or new prescription. In other cases, there may be insurance coverage barriers, shortage-related pricing changes, or limited availability through our normal ordering channels.

In certain cases, a $20 Medication Access Consultation Fee may apply when your medication requires special procurement through a non-traditional supplier due to limited availability or elevated acquisition costs.

Please note that availability may vary by medication, strength, dosage form, manufacturer, and insurance coverage. Unfortunately, at this time, we cannot guarantee certain manufacturers, as availability is based on current product supply. We do not carry brand name patches; however, do carry the generics which 95% of patients use.

Already receive hormone medications from Skippack Pharmacy? You do not need to complete this form again. We only need it submitted once.

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

How Did You Hear About Us?

How did you want to receive this medication?

Select the name of the hormonal patch(es) you take.

Select the name(s) of the ORAL hormonal medication(s) you take (if any).

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.

In some cases, obtaining your patches (if applicable) may require additional pharmacist review and coordination through non-traditional suppliers. If needed, would you be willing to pay a $20 Medication Access Consultation Fee? [The fee only applies in select situations where additional pharmacist time and special procurement efforts are required.]

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