SJM College of Pharmacy - Drug Information Service


*First Name
 
*Last Name
 
Degree
Profession
*Phone Number
 
*Email Address 
   
*Practice Site (Eg: Name of Pharmacy, Clinic, Hospital, or Organization)    
*Location (Eg: City, State)
 
*Preferred Response Method
Email     Phone
*Request Information    

 

Pertinent Patient information

*
Age
Months :    Years :
*Gender
Male     Female
*
Weight
   

Note: Please provide patient information that you feel may be helpful in answering the drug information request (such as patients age, disease states, or medications)
*Star marked information is mandatory to provide

When do you need a response (Today, Tomorrow, Next week)?

**Note: If your request is received late in the day, we may not be able to respond until the next business day.

Purpose of the enquiry
* Security Code