Drug Shortage Request Form - Plaquenil (Hydroxychloroquine Sulfate)

Patients taking Plaquenil® (Hydroxychloroquine Sulfate) may be having a hard time finding their maintenance medication due to increased demand from the coronavirus pandemic. Our pharmacy staff specializes in preparing medications from scratch using a state-of-the-art compounding lab.

First Name * Last Name * Date of Birth Best Phone Number *

Medication Details

Therapy details * Do you have a current active prescription? Quanitity Requested

Health Care Provider Information

A prescription from a licensed provider is required for compounded medications.

Practitioner Name Practice Location Practice Phone Number Notes to the Pharmacist