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Non formulary request form

Non formulary medication request form 2026

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The document is a Non-Formulary Medication Request Form from the Department of Pharmacy, which must be completed by attending physicians to order and dispense non-formulary drugs. It outlines the requirements for initiating therapy, the potential cost implications, expected delays in drug availability, and the need for clinical justification if formulary alternatives are not suitable.

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Click ‘Get Form’ to open the non-formulary medication request form in the editor.
Begin by pasting the patient information label in the designated area at the top of the form.
Fill in the 'Date of order' field with the current date to ensure accurate processing.
Enter the 'Name of medication', 'Dose', 'Frequency', and 'Dosage form' as per your prescription details.
Specify the 'Expected duration of therapy' to provide clarity on treatment length.
Indicate the prescriber’s name and include a clinical reason if a formulary therapeutic substitution is not appropriate.
Ensure that the physician signs and stamps the form before submission for pharmacy processing.

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