Description
Dermatology Enrollment Form
Customizable dermatology enrollment form pharmacy owners can provide to prescribers.
Specialty medications listed on form:
- Cosentyx
- Dupixent
- Enbrel
- Erivedge
- Humira
- Odomzo
- Otezla
- Siliq
- Simponi
- Stelara
- Tremfya
The form includes the following sections:
- Heading – pharmacy can input their contact details manually or electronically
- Patient Information – personal information of the patient
- Prescriber Information – Practice details
- Diagnosis & Clinical Information
- Prescription Information
- Custom Formula – prescriber can enter a custom formulary
- Prescriber Signature – includes a disclaimer
