Guest Dosing Request
To be filled out by Home Clinic
CompDrug
547 E 11th Avenue Columbus, OH 43211 Phone: 614.224.4506 Fax: 614.291.0118
Medication Hours
Mon, Thurs, & Fri: 6am - 1pm Tues & Wed: 530am - 1pm Saturday: 6am - 9am Sunday: Closed
Patient Information
Patient Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
SSN
*
Race
*
Please Select
American Indian/Alaska Native
Asian
Black or African American
Native Hawaiian/Other Pacific Islander
White
Multi-Racial
Unknown
Refuse to Identify
Gender
*
Please Select
Male
Female
Male transitioning to Female
Female transitioning to Male
Clinic Information
Name of Home Clinic
*
Address of Home Clinic
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Clinic Phone Number
*
Please enter a valid phone number.
Clinic Fax Number
*
Please enter a valid phone number.
Clinic Email
example@example.com
Medication Information
Type of Medication
*
Please Select
Methadone
Suboxone
Vivitrol
Medication Dose
*
mgs Per Day
Date to Start Medication
*
-
Month
-
Day
Year
Date
Date to End Medication
-
Month
-
Day
Year
Date
Dose Confirmed By:
*
Must be Physician, RN, or LPN
Is Patient Transferring?
*
Please Select
YES
NO
Click Here for Transfer Criteria
Per CompDrug's Medical Director, patients can guest dose for a maximum of 14 days.
Picture ID is required Cost: $20 per day (
correct change, money order, or credit card
) Payment is required on day of service This form must be completed & returned prior to medication Please notify CompDrug if guest dosing services are canceled A Release of Information
MUST
accompany this request A lock box is required on Saturday for Sunday & Holiday take-home medication Lock box must be ALL metal with key or combination lock No take-home medication is given for guest dosing with the exception of Sundays and holidays We will not guest dose above 200mgs of Methadone a day
Signature of person completing this form
*
Prohibition on Re-Disclosure
42 CFR part 2 prohibits unauthorized disclosure of these records
Submit
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