Formulary Request Form

All sections of this form must be completed by the clinician making the request.
The Formulary Committee will consider this proposal after a complete review has been completed.

*Denotes required field

FORMULARY REQUEST CONFLICT OF INTEREST STATEMENT

Having an interest or affiliation with a Pharmaceutical Company does not prevent a practitioner from requesting a Formulary addition or change. However, such relationships may subject that requestor to a potential conflict of interest. A conflict of interest does not disqualify a requestor or guest from the Committee's discussion prior to the vote.

Please note all relationships with potentially conflicting entities within the last 12 months