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

Department Chair/Service Line Leader Approval*  

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

 


For further information regarding Formweb
please call 800.467.1907.