M-D-Y H:M
Patient's First Name
* must provide value
Patient's Last Name
* must provide value
Patient's Date of Birth
* must provide value
M-D-Y
Phone Number
* must provide value
In case we need to call you back
When can we best reach you
Patient Delivery Address:(copied from below, if applicable)
Yes No
Please select your relation to the patient
* must provide value
Spouse / Partner
Parent / Guardian
Child
Caregiver
Doctor / Nurse
Other
Spouse / Partner
Parent / Guardian
Child
Caregiver
Doctor / Nurse
Other
Enter your relation to the patient
* must provide value
Please enter your name
* must provide value
Hello, ______ ! Thanks for helping us take care of ______ ! Please choose the clinic you are seen in that prescribes the medication(s) that our Specialty Pharmacy manages
* must provide value
Asthma, Sinus, & Allergy Cystic Fibrosis Dermatology Endocrinology GI / IBD Hematology Hepatology HIV PrEP Infectious Disease IPF / PAH MS Neurology Oncology Psychiatry Rheumatology Other / None of the above
As of September 1, 2021, refills for Praluent and Repatha are being managed by a different department at VUMC - the Retail Support Pharmacy. Please click this link to be directed to the appropriate online refill form. Orders will continue to be shipped to your door at no additional cost. If you have questions, please refer to the letter you received or call (615) 875-4999.
If the link above does not work, try copying and pasting the following URL into your browser's address bar: https://redcap.vumc.org/surveys/?s=YYM3JNM8XM
How can we help you?
* must provide value
Select all that apply
What would you like to ask the pharmacist about?
* must provide value
What questions do you have for the pharmacist about ______ ?
Please describe how we can help you
* must provide value
Which medication(s) or medication-related supplies do you need to have filled?
* must provide value
Enter medication name(s) and strength(s) or supply name(s) and quantity needed
Have there been any changes with your insurance since your last refill?
* must provide value
Yes
No
Please provide any details about the insurance change: If you have a new insurance card, please include the information printed on it: Insurance Start Date: Member ID: Rx BIN: Rx PCN: Rx Group:
How many days supply do you currently have on-hand?
* must provide value
0
1-3
4-6
7-9
10 or more
Insurance Start Date (if known)
M-D-Y
Since your medication was last filled, have you:
Experienced any side effects? Missed any doses? Had any problems taking (or the administration of) your medication? Had any ER visits or hospitalizations? * must provide value
Yes No
Select all that apply
How many doses have you missed?
* must provide value
1-2
3-4
5 or more
Please enter more information about: ______
* must provide value
Since your medication was last filled, have you:
Developed any new food or drug allergies? Developed any new conditions or diagnoses? Had any changes to your prescription? * must provide value
Yes No
Please enter more information about: ______
Since your medication was last filled, have you:
Developed any new food or drug allergies? Developed any new conditions or diagnoses? Experienced any height or weight changes? Had any changes to your prescription? Yes No
Please enter more information about: ______
* must provide value
Because of your disease state, have you:
Missed school or work? Been unable to perform planned activities? * must provide value
Yes No
Please provide details (if appropriate) regarding missed work, school, or inability to perform planned activities due to your disease state
* must provide value
Because of your disease state, have you:
Missed school or work? Been unable to perform planned activities? Had any negative changes to your level of energy or exercise tolerance? * must provide value
Yes No
Please provide details (if appropriate) regarding: ______
* must provide value
How well is the medication working?
* must provide value
Poor
Fair
Good
Excellent
Any changes to your symptoms?
* must provide value
No Change
Improved
Worsened
No Change
Improved
Worsened
Please add any additional details about your symptom changes.
* must provide value
Since your medication was last filled, have you had any flares, relapse, or exacerbation?
* must provide value
Yes No
Did this require additional medication such as steroids to resolve?
* must provide value
Yes No
Please provide any details regarding your recent exacerbation, relapse or flare since your last refill or any new medications started to treat an exacerbation.
* must provide value
Do you have any questions about your medications, or would you like to speak with a pharmacist?
Yes No
What questions do you have for the pharmacist?
* must provide value
How would you like to receive your medication?
* must provide value
Pick Up Delivery
At which location would you like to pick up?
TVC - The Vanderbilt Clinic
MCE - Medical Center East
VCH - Vanderbilt Children's Hospital
OHO - One Hundred Oaks
TVC - The Vanderbilt Clinic
MCE - Medical Center East
VCH - Vanderbilt Children's Hospital
OHO - One Hundred Oaks
What day would you like to pick up?
* must provide value
M-D-Y
Sorry! ______ is not open on the day you selected. Please choose another date. We are open for shortened hours at MCE and VCH on Saturdays, and we are open throughout the week at all of our pharmacy locations. See above for the hours of operation and addresses for each location. We are also able to schedule delivery directly to your home at no cost to you.
We may contact you if we are unable to have your order filled by the requested pick-up date and/or time.
Sorry! We are not open for pick up on the day you selected. Please choose another date. TVC (The Vanderbilt Clinic) Pharmacy is open Monday through Friday from 8:00am to 6:00pm and is closed on weekends and major holidays. We are also able to schedule delivery directly to your home at no cost to you.
We may contact you if we are unable to have your order filled by the requested pick-up date and/or time.
Whoops! Please choose a pick up date in the future.
Please allow at least two business days for us to fill your order.
Some orders take longer to process or medications may need to be ordered. Because of this, orders may not be ready until after 1:00pm (13:00) on the day of pick up.
We may contact you if we are unable to have your order filled by the requested pick-up date and/or time.
Sorry! We're only able to schedule orders up to 9 days from now to make sure the info you gave us earlier is still correct when it's time to fill your order. Please select a date in the next 9 days. We may contact you if we need to confirm or reschedule any pick-ups requested further out than 9 days. We apologize for any inconvenience.
What time would you like to pick up?
H:M
Sorry! That may be just a little sooner than we can have your order ready for pick-up. We try to be pretty quick, and would love to be able to have it filled by then, but we'll need a bit more time to make sure we have everything you requested, and that it's all correct.
Please allow at least two business days for us to fill your order.
Some orders take longer to process or medications may need to be ordered. Because of this, orders may not be ready until after 1:00pm (13:00) on the day of pick up.
We may contact you if we are unable to have your order filled by the requested pick-up date and/or time.
Please enter the full address where the package should be delivered
* must provide value
Note: We may reach out for confirmation if we have never delivered your medication to this address before.
What kind of address is this?
* must provide value
Home / Permanent
Work / Business
Temporary / Vacation
Home / Permanent
Work / Business
Temporary / Vacation
What is the first day you will be at this address?
* must provide value
M-D-Y
And what date will you be leaving this address?
* must provide value
M-D-Y
When would you like to receive the delivery?
Note: Delivery availability is limited on Saturdays, and is not available on Mondays, Sundays, or major holidays.
* must provide value
M-D-Y
Whoops! Please choose a delivery date in the future.
Please allow at least two business days before delivery.
Some orders take longer to process or medications may need to be ordered. Because of this, orders may take two business days before delivery. Delivery availability is limited on Saturdays, and is not available on Mondays, Sundays, or major holidays.
We may contact you if we are unable to have your order delivered by the requested date. We apologize for any inconvenience.
Sorry! We are unable to deliver on the date you selected. Please choose another date for delivery, or give us a call at (866) 321-8664.
Delivery availability is limited on Saturdays, and is not available on Mondays, Sundays, or major holidays and the day after.
Please allow at least two business days before delivery.
Some orders take longer to process or medications may need to be ordered. Because of this, orders may take two business days before delivery.
We may contact you if we are unable to have your order delivered by the requested date. We apologize for any inconvenience.
Whoops! Looks like that's after you're leaving. If you'll be at a different address on the delivery date, please re-enter the new one.
Whoops! Looks like that's the day you're leaving. We can't guarantee your package will arrive before you leave. If you'll be at a different address on the delivery date, please re-enter the new one.
Whoops! Looks like that's before you get to the temporary address. If you'll be at a different address on the delivery date, please re-enter the new one. Sorry! That may be just a little sooner than we can have your order ready for delivery. We try to be pretty quick, and would love to be able to have it filled by then, but we'll need a bit more time to make sure we have everything you requested, and that it's all correct.
Please allow at least two business days before delivery.
Some orders take longer to process or medications may need to be ordered. Because of this, orders may take two business days before delivery. Delivery availability is limited on Saturdays, and is not available on Mondays, Sundays, or major holidays.
We may contact you if we are unable to have your order delivered by the requested date. We apologize for any inconvenience.
Sorry! We're only able to schedule orders up to 9 days from now to make sure the info you gave us earlier is still correct when it's time to ship your order. Please select a date in the next 9 days. We may contact you if we need to confirm or reschedule any deliveries requested further out than 9 days. We apologize for any inconvenience.
Is a signature required for delivery?
* must provide value
Yes No
Note: Medicaid requires a signature for all deliveries.
Payment of all co-pays/medication expenses will be charged prior to delivery. Has your credit card or payment information changed since the previous order?
* must provide value
Yes
No
I never gave you one
Yes
No
I never gave you one
If you typically have a copay amount, please provide the last 4 digits of the CC on file to be charged.
Would you like to receive an email confirmation that your order was received and tracking information via email when your order is shipped?
Yes No
Please enter your email address
Great! We're all set! We will use the card that was billed for your last order. If the copay has changed or we run into any problems, we will give you a call.
New card? No problem! We have a secure, dedicated phone line for taking credit card info. We will give you a call to get the new card information, and then we'll work on getting your order shipped out to you.
No card, no problem! If you have a copay this time, or we have any other questions, then we will give you a call. Please add any additional notes for the delivery
Note: UPS may not be able to accommodate all requests.
Vanderbilt Specialty Pharmacy | Hours and Contact Information
Monday - Friday Saturday Sunday
All major holidays (unless otherwise announced)
7:00am - 7:00pm 8:00am - 12:00pm Closed
Closed
General questions
Consulting pharmacist
Pharmacist on call (emergency 24-hour coverage)
(615) 875-0080
(866) 321-8664 (toll-free)
(866) 321-8664 (toll-free)