Vivitrol Enrollment Survey
Please complete this survey to help us determine your eligibility for Vivitrol treatment.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Have you ever received Vivitrol treatment before?
*
Yes
No
Please select the conditions you are seeking treatment for:
*
Opioid Use Disorder
Alcohol Use Disorder
Other
Please list any current medications or allergies:
Do you have any of the following medical conditions? (Select all that apply)
Liver disease
Kidney disease
Pregnancy or breastfeeding
None of the above
Other
Submit Enrollment Survey
Should be Empty: