Non-Subsidized and Non-Formulary Medications Request Form, University Health System, Hospital, San Antonio, Texas

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For Provider Use Only

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Patient Name:

D.O.B.

/ / ex. mm/dd/yy

MRN#:

Diagnoses:

Requesting Prescriber:

Department:

Office contact person :

Provider Ext/Pager:

Provider E-mail:

Medication Requested:

Dosage Strength:

Frequency:

Estimated Length of Therapy:

Pharmacy Location:

UH	UHC-D	UFHC-SE	UFHC-SW	UCCH

Reason for Non-Subsidized Medication:

Previous Medications Used for this Diagnosis: (indicate any problems w/ previous Rx):

Medication Allergies: