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Patient Request Form

Drug Information Center

Requestor's Contact Information: Items marked with an asterisk (*) are required. You may withhold your name.

First Name
Last Name
Address
City *
State *
Zip *
Telephone *
Fax
Email *
Request/Question

Pertinent Patient Information:

Note: Please DO submit information that you feel may be helpful in answering the drug information request (such as your age, disease states, or medications). Due to HIPAA regulations please DO NOT submit patient identifying information (such as birth date, hospital room number, social security number, or medical record number). All drug information request forms and other records pertaining to those requests are maintained in a secure place and will be kept confidential.

Age
Gender
Weight
Height
Allergies
Diagnosis/Disease State
Current Medications
Preferred Method of Response:
Best time to call
Best Appointment Day/Time

Disclaimer

Data contained in or linked to these pages is provided as a service and is intended to be a supplemental
drug information resource for health care professionals and community lay persons. This service is not a
replacement for medical or pharmaceutical care. All medical concerns or inquiries should be directed to
appropriate licensed health care professionals.

Reasonable efforts will be made to post accurate and timely information within these pages. However,
Elizabeth City State University makes no warranties concerning the accuracy, completeness or reliability
of the information and does not endorse the content or views of any linked materials.