Fillable Print-request-form Drug Information Request Form

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Print-request-form Drug Information Request Form

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U.S.A. forms for Elizabeth City State University

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www.ecsu.edu/druginfocenter
ECSU Drug Information Center
With support from the North Carolina GlaxoSmithKline Foundation
101 East Ehringhaus Street
Elizabeth City, NC 27909
Phone: 252-331-1558 Toll Free: 888-278-2906
Fax:
252-331-2491 Toll Free: 888-277-8653
24/hr Appointment Request Line:
252-335-8745
Drug Information Request Form Date:
You may EMAIL requests to druginfocenter@mail.ecsu.edu. Our goal is to respond within 3 business days.
Requestor’s Contact Information: Items marked with an asterisk (*) are required.
First Name: *
Last Name:*
Address: *
City: * State * Zip *
Telephone:
* Fax
Email:
Affiliation:
____ ECSU ____ Pharmacy
____ Hospital:
___ Other Organization _______________________________________________________________________________
Requestor’s Status:* (Required – please select one)
Pharmacist
Physician
Nurse
Family Nurse Practitioner
Dentist
Physician’s Assistant
OT/PT
Industry
Patient/Consumer
____Other (Please specify if other:_____________________________________________________________________________)
Request/Question:
1
Print Form
Submit by Email
2
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(s): ________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Current Medications: ___________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Type of Request:
____ Product Identification ____ Pregnancy/Lactation
____ Dosage/Administration ____ Abuse/Addiction
____ General Information ____ Toxicology
____ Drug Availability ____ Cost
____ Adverse Dr
ug Reaction ____ Kinetics
____ Drug Interactions ____Investigational Drug
____ Therapeutic Use ____ Stability/Compatibility
____ Literature Retrieval ____Other (specify below)
Other: _________________________________________________________________________
_____________________________________________________________________________________
Preferred Method of Response:
___Email
___Phone
___Fax
Our goal is to respond within 3 business days.
ECSU Drug Information Center
With support from the North Carolina GlaxoSmithKline Foundation
101 East Ehringhaus Street Phone: 252-331-1558
Elizabeth City, NC 27909 www.ecsu.edu/druginfocenter
Call Center Hours
Monday-Friday 9:00 a.m. to 5:00 p.m.
The DIC observes the University’s holiday schedule.
Note: You may FAX your request to 252-331-2491 or fax free to 888-277-8653
PLEASE SEE DISCLAIMERS BELOW BEFORE SUBMITTING FORMS VIA EMAIL.
www.ecsu.edu/druginfocenter
ECSU Drug Information Center
With support from the North Carolina GlaxoSmithKline Foundation
101 East Ehringhaus Street
Elizabeth City, NC 27909
Phone: 252-331-1558 Toll Free: 888-278-2906
Fax:
252-331-2491 Toll Free: 888-277-8653
24/hr Appointment Request Line:
252-335-8745
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.
Call Center Hours
Monday-Friday 9:00 a.m. to 5:00 p.m.
The DIC observes the University’s holiday schedule.
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Completed 4 January 2020

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