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Drug Information Service Online Consultation
Request Form
First Name
Last Name
Degree
Profession
Pharmacist
Nurse
Physician
Dentist
OT/PT
Other
Specify if "Other" Profession
Phone Number
Email Address
Location (e.g., City, State)
Practice Site (e.g., name of pharmacy, clinic, hospital, or organization)
Are you a PharMerica employee or affiliate?
Yes
No
Are you a CHI Health employee?
Yes
No
Preferred Response Method
Phone
Email
Fax
Request Information
Pertinent Patient Information
Preferred response time (Note - For non-contracted clients: While every effort will be made to respond in a timely fashion, we will contact you in the event that we cannot address your question(s) within the requested timeframe.
24-48 hours
By End of Week
Sometime Next Week
No Rush
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