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Medication Request

This form is for requesting medications NOT found on the vxVistA drug file list or order menu.
This form may also be used to request Meds from elsewhere, OTC/Herbals/etc. to be added to the list of selectable items.

Generic Medication Name:
Medication Trade Name:
NDC Number: (if known):
Usual Dosages Prescribed:
Route:
Usual Schedules:
Special Instructions:
Requested By:
Requestor's Name
Approved by
Approved Date
Email
CAC's Name