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Drug Information 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
Affiliation

ECSU
Pharmacy
Hospital 
Other Organization

Requestor's Status *
Other Status If you selected "Other" as your Requestor's Status, please specify.
Request/Question

Pertinent Patient Information:

Note: Please DO submit patient information that you feel may be helpful in answering the drug information request (such as patient's age, disease states, or medications). Due to HIPAA regulations please DO NOT submit patient identifying information (such as patient's name, birth date, hospital room number, social security number, or medical record number).
Age
Gender
Height
Weight
Allergies
Diagnosis/Disease State
Current Medications
Type of Request
Product Identification Pregnancy/Lactation
Dosage/Administration Abuse/Addiction
General Information Toxicology
Drug Availability Cost
Adverse Drug Reaction Kinetics
Drug Interactions Investigational Drug
Therapeutic Use Stability/Compatibility
Literature Retrieval Other
Other Request If you selected "Other" as your Type of Request, please specify.
Preferred Method of Response: Email
Phone
Fax 

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.