Pharmaceutical Drug Release Form
Complete this form to authorize and document the release of pharmaceutical drugs to authorized recipients.
Recipient Full Name
*
First Name
Last Name
Recipient Organization / Department
*
Recipient Contact Email
*
example@example.com
Recipient Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Drug Name
*
Batch/Lot Number
*
Dosage Form (e.g., tablet, injection)
*
Please Select
Tablet
Capsule
Injection
Liquid
Ointment
Other
Quantity Released
*
Purpose of Release
*
Please Select
Patient Treatment
Clinical Trial
Sample Distribution
Research
Other
Release Date and Time
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Storage and Handling Confirmed by Recipient?
*
Yes
No
Special Instructions or Comments
Responsible Staff Member Name
*
Recipient Signature
*
Submit Release
Submit Release
Should be Empty: