Buprenorphine ER Refill Request
If you need delivery same day, please contact Elissa at the pharmacy at (215)471-4000x0. By completing this form, you agree that you will not transfer, sell, or distribute Sublocade. 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 DOB
*
-
Month
-
Day
Year
Date
Has the patient started or stopped any medications since the last fill of buprenorphine ER?
Please Select
Yes
No
What medications have been started or discontinued? (if new medication, please include name, dose, and directions)
Delivery Address for buprenorphine ER (if different than previous delivery address). Delivery address MUST match the administering provider's registered DEA address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What medication and dose would you like to be delivered?
*
Please Select
Brixadi 8mg
Brixadi 16mg
Brixadi 24mg
Brixadi 32mg
Brixadi 64mg
Brixadi 96mg
Brixadi 128mg
Sublocade 100mg
Sublocade 300mg
When is the patient scheduled to receive buprenorphine ER? (if no set appointment time, choose earliest time)
*
When would you like buprenorphine ER to be delivered to the delivery address listed above?
*
Who will be administering buprenorphine ER to the patient?
*
First Name
Last Name
Administering Provider's DEA Number (optional, only complete if different than prescriber)
Administering Provider's NPI Number (optional, only complete if different than prescriber)
Additional notes for pharmacy staff (optional)
If you would like a confirmation email, please enter your email below:
example@example.com
Submit
Should be Empty: