Model of Drug Information Request Form

1. Hospital/private Nursing Home Name
Address:
Pharmacy Department
Drug Information Request Form
Date:.............................................
Requestor’s Details:
First Name: ……............. Middle Name: …………………… Last Name: .......................
Address:
Province: ..... District: ............ Zone: ....Municipality/Rural Municipality: .....Ward No.: .........
Telephone/Mobile No: ........................................ Fax No...................... Email:
.............................................
Organization: Hospital/Pharmacy/Nursing/Other: .................................................................................
Requestor’s Designation:
Pharmacist Physician Nurse Dentist Physician’s Assistant
Patient/Consumer Other:
Request/Question/Problem:
Patient Details:
Patient Code:........ Age: ........... Gender: .............
Height: ............. Weight: ............. Prgnnancy/Lactation........
Medication History: ........................................................................................................................
Medicine Allergies:............................................................................................................................
Diagnosis/Disease State:.....................................................................................................................
Current Medications:...........................................................................................................................
Type of Request:
Product Identification
Pregnancy/Lactation
Drug of Choice
Dosage/Administration
Abuse/Addiction
Dose Calculation for child
General Information
Toxicology
Dose Adjustment in Kidney
failure
Drug Availability
Cost
Dose Adjustment in
Kidney failure
Adverse Drug Reaction
Pharmacokinetics
(LADME)
Vaccine Safety
Drug Interactions
Investigational Drug
Dosage form Formulation
(excipients)
Therapeutic Use
Stability/Compatibility
Other (specify below)
Laws/policy/procedure
Teratogenicity/Genetic
effects
Other
....................................................................................................................................................................

2. Preferred Method of Response: Email Phone Fax Other
Solution of Problem/ answer/Response
Reference: .................................................................................................................................................
Information Provider:
Name:
Designation:
Signature
Date;Time:
Name of Drug Information Center
Address:
Phone.......................... Mail Address: .................................. Fax..................................
Website:..........................................