Formulary Intake Form - Shared Health

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MEDICATION INFORMATION

Reason for Request:*

New medication

New Indication of an existing formulary medication

New formulation of an existing formulary medication

Other

Reason for Request – Other:*

Generic name:*

Brand/trade name:

Manufacturer:

Dosage form and strength:*

Usual dose and frequency:*

Route of administration:*

List the indication(s) for this formulary application:*

Typical treatment duration for the indication(s) applied for:*

Single dose therapy

Limited treatment duration (e.g. maximum 2 months, maximum 8 doses, etc.)

Chronic/long term therapy (including therapies that would be continued post-discharge)

Typical number of doses and treatment duration for a time limited course:*

Estimated number of treatment courses per year or new patient initiations expected per year in Shared Health or Service Delivery Organization facilities:*

CLINICAL JUSTIFICATION AND CRITERIA FOR USE

Summarize the medication's role in therapy including: a) Specific criteria for use. b) Major advantages that warrant formulary addition.*

Do you recommend that this medication replace an existing formulary medication?*

Yes

No

Please specify which medication it will replace:*

Please explain why it is not intended as a replacement:*

Do you recommend this medication be restricted to a specific physician, service, program, or level of care?*

Yes

No

Please specify what restrictions are recommended and why?*

Are there any special monitoring or administration requirements (e.g., special pump, equipment, diagnostic tests, or handling considerations)?*

Yes

No

Please explain or list all special requirements:*

Attach published literature (i.e. peer-reviewed controlled studies, clinical guidelines, Common Drug Review, etc.) supporting this request:*

Drop files here or

Max. file size: 2 MB, Max. files: 5.

Please cite any additional published literature (e.g., peer-reviewed studies, clinical guidelines, Common Drug Review reports, etc.) supporting this request that you were unable to upload:

REQUEST DETAILS

Requested Priority of Assessment:*

Priority 1: Unique medication with a significant impact on morbidity and mortality

Priority 2: New medications belonging to an existing class or those where acceptable options currently exist

Unsure: Formulary review committee to assess

Is this request also being submitted to the Provincial Oncology Drug Program?*

Yes

No

Has this request been reviewed with the Department Head/Provincial Clinical Program Lead/Program Director?*

Yes

No

Please provide the full name of the Department Head/Provincial Clinical Program Lead/Program Director:*

Department Head/Provincial Clinical Program Lead/Program Director Email Address:*

Upon submission of this form, the Head/Lead/Director will be contacted via email provided below to complete the submission to the formulary committee for consideration.

REQUESTER INFORMATION

Requester's name:*

Requester Title/Role/Clinical area:*

Requester email address:*

Requester's Conflict of Interest Declaration:*

Note: Disclosure of a potential conflict of interest will be reviewed by the Provincial Pharmacy and Therapeutics Committee as part of the evaluation process. Such disclosure does not automatically disqualify the request.

Provide details of any funding or support that you or your department/program have received from the manufacturer or marketer of this product (e.g., research grants, professional retainers, consulting fees, or educational support).

Additionally, please disclose any contact with industry you may have had regarding this medication/submission.

Date of submission (dd-mm-yyyy):*

Requester Signature:*

Use your mouse / stylus / touchscreen to sign.