Get Pep Drug Replacement Form. Form To Request Replacement Post Exposure Prophylaxis Drugs. - Health

Filling out the PEP Drug Replacement Form is an essential step for individuals who require replacement Post Exposure Prophylaxis drugs. This guide provides clear instructions to help you complete the form accurately and efficiently, ensuring that all necessary information is submitted.

Follow the steps to complete the form easily and effectively.

1. Press the ‘Get Form’ button to obtain the PEP Drug Replacement Form and access it in an editor of your choice.
2. Begin by filling in the patient code and age in the respective fields. This information identifies the individual who has been prescribed PEP.
3. Select the gender of the patient by marking the appropriate box provided.
4. Enter the UR number as required by the pharmacy in the designated field.
5. Specify the country of residence if applicable in the provided space.
6. In the PEP Assessment section, indicate the type of sexual contact that represents the primary exposure of concern by checking the corresponding box.
7. Fill in the time since exposure in hours to provide context for the pharmacy.
8. Confirm whether shared injecting equipment was involved by selecting ‘Yes’ or ‘No’.
9. State the gender of the source and select the appropriate risks involved.
10. Indicate whether a condom was used during the exposure.
11. Select the source HIV status by marking the corresponding box.
12. If applicable, provide risk characteristics of the source partner.
13. Report if a starter pack was dispensed, including whether it was broken or not.
14. Indicate if the source is HIV-positive, negative, or unknown.
15. Check the source HIV risk by selecting the relevant category.
16. Fill out the source antiretroviral use status.
17. Indicate whether the person has taken PEP in the last 12 months and provide details if yes.
18. If multiple Starter Packs were dispensed, explain how many and the reason.
19. Confirm whether four weeks of PEP was prescribed.
20. Fill out the name of the Infectious Diseases Physician consulted and the consultation date.
21. Complete the drug prescribed, dose, and duration information.
22. Enter the prescriber’s name, signature, date, provider number, practice address, and telephone number.
23. Provide the pharmacist’s name and the name and address of the dispensing pharmacy.
24. Get the pharmacist to sign and date the form.
25. Finally, save your changes, and choose the option to download, print, or share the form as needed.

Complete your PEP Drug Replacement Form online today for a seamless experience.