Formulation Request Form

Formulation Request Form
*RPh or Tech Name:
*Date & Time
MonthDayYear
Date
Doctor's Information
*Customer ID:
*Person of Contact:
*Practice and Doctor Name
Prescriber DEA (required for CDS orders)
Address
Prescriber Street Address
Street Address Line 2
CityState, Zip
Postal / Zip Code
*How Does Office Want to be Contacted? (Check one)
PhoneEmailFax
Phone/Fax/Email to contact

Flavor or Any Additional Information That Would be Helpful for the Request: (Example: What they would be treating)

Click 'Save Formulation Request' button and print to PDF. Save to U:CSFormulationRequests Name file as: CUSTID MMDDYYYY Yourinitials (BRYA628 01012020 TLB)
Should be Empty: