Bank's Apothecary Sublocade Delivery Request Form

Bank's Apothecary Sublocade Delivery Request Form

This May NOT be used as a Prescription Order Form
Sublocade delivery requests received by Bank's Apothecary will ship a minimum of one business day after receipt of this form.

In order to avoid delays receiving your medication, please submit all delivery requests a minimum of 2 business days prior to the date your office is requesting delivery.

Questions? Call 267-921-0921.

Medication Will Not Be Sent Unless All Lines Have Been Completed
Today's Date*

MonthDayYear
Date
Patient Name*

First NameLast Name
Patient DOB*

MonthDayYear
Date
Patient’s Phone #*

Area CodePhone Number
Dose Type*

LoadingMaintenance
Last Loading Dose Injection Date

MonthDayYear
Enter date if applicable
Dosage Amount*
Patient’s Last Injection Date

MonthDayYear
(or indicate if initiation dose)
Patient’s Last Injection Date*

MonthDayYear
(or indicate if initiation dose)
Patient’s Scheduled Injection Date*

MonthDayYear
Date
Medication Delivery Date Selection*

MonthDayYear
Date
Office Address Where Medication Is Being Delivered/Administered*

Street Address

Street Address Line 2

CityState

Postal / Zip Code
Name and title of contact person (for Sublocade)*

First NameLast Name
In accordance with the Sublocade REMS Program, I attest that this medication will ONLY be used in this office and will NOT be transported to any other location/office/person or given to the patient. Typing your name here will act as your digital signature.*

First NameLast Name
Phone # of Contact Person*

Area CodePhone Number
Fax #

Area CodePhone Number
Email Address of Contact Person (optional)
example@example.com
Additional Email Address (Optional)
example@example.com
Doctor's Name*

First NameLast Name
Doctor’s DEA # (for above registered location)*
Notes

0/250
Should be Empty: