Buprenorphine ER Enrollment Form
Form will be automatically sent to Sunray Specialty Pharmacy for processing. Please send an electronic prescription along with this form to avoid delays. This form does NOT act as a prescription for buprenorphine ER. If you need delivery same day, please call Elissa at the pharmacy at (215)471-4000x0. This form will not allow orders that are due within 3 hours. By completing this form, you agree that you will not transfer, sell, or distribute buprenorphine ER. You attest that this medication will only be used in the office specified and will not be transported to any other location, office, or person or given directly to the patient.
Patient's Name
*
First Name
Last Name
Patient's Date of Birth
*
-
Month
-
Day
Year
Date
If patient has Medicare, please include last 4 numbers of patient's social security number so that insurance information can be searched:
Patient's Phone Number
Please enter a valid phone number.
Patient's Height
Patient's Weight
Allergies to Medications and Reactions
*
Concomitant Medications (please include drug name, dose, and frequency)
*
Prescriber's Name
*
First Name
Last Name
Prescriber's DEA Number
*
Office Address where buprenorpine ER is being delivered and administered. Delivery address MUST match the administering provider's registered DEA address.
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Is the patient being prescribed Brixadi or Sublocade?
*
Please Select
Brixadi
Sublocade
What dose type is this for the patient?
*
Loading dose (Sublocade 300mg)
Maintenance dose (Sublocade 100mg)
Maintenance dose (Sublocade 300mg)
What dose is being prescribed for the patient?
*
Brixadi 8 mg once weekly
Brixadi 16 mg once weekly
Brixadi 24 mg once weekly
Brixadi 32 mg once weekly
Brixadi 64 mg once monthly
Brixadi 96 mg once monthly
Brixadi 128 mg once monthly
Has the patient received a buprenorphine-containing product for at least 7 days prior to the scheduled Sublocade administration?
*
Yes
No
When is the patient scheduled to receive buprenorpine ER? (if no set appointment time, choose earliest time)
When would you like buprenorphine ER to be delivered to the delivery address listed above?
*
When would you like Sublocade to be delivered to the delivery address listed above?
-
Month
-
Day
Year
Date
Who will be administering buprenorphine ER to the patient?
*
First Name
Last Name
Administering Provider's DEA Number (optional, only need to complete if not the prescriber)
Administering Provider's NPI Number (optional, only need to complete if not the prescriber)
Who is the best contact for Sublocade at this practice?
First Name
Last Name
What is the best phone number to reach the designated contact? (optional)
Please enter a valid phone number.
What is the designated contact's email address? (optional)
example@example.com
Please upload most recent office notes for the patient in reference to buprenorphine ER
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