Drug Line Extension/Deletion Request
Rpharmy Memorial Formulary and Informatics Subcommittee
Department of Pharmacy
Chair: Pharma Fairy, PharmD, MS, BCPS
Email: lpaxton@rpharmy.com
Use this form to request the addition or deletion of a dosage form or strength to a pre-existing drug on the Rpharmy Memorial Hospital Formulary of Accepted Drugs
*Request is for a line item:
If requesting a drug line extension, request is for a new:
*Will this request require changes in Alaris pump guardrails?
*Will this request require changes in Medication Administration Guideline (MAG)?
*Requestor's affiliation within RMH:
*Request has been discussed with other RMH institutions:
*If approved, the request is to be implemented at:
 



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