Pharmacy Plaintiff Intake

Pharmacy Plaintiff Intake

Did a pharmacy deny you a prescription for medication your doctor prescribed you for treatment of COVID-19? Are you a physician who wrote a prescription for medication to treat COVID-19 that was denied by a pharmacy? Are you a pharmacist that has been prohibited (or hassled) from filling a prescription for medication to treat COVID-19 by corporate policies? If you fit one of these three criteria and would like to join AFLDS as a plaintiff in a lawsuit at no cost to you, please provide us with the following information. (This information will be kept confidential unless you choose otherwise.)
Name *

First Name Last Name
Email *
example@example.com
Phone Number *
Please enter a valid phone number.
Address *

Street Address

Street Address Line 2

City State

Zip Code
Location of Event *
Zip Code
State of Event *
State
Which best describes your role in this event? *

Patient Patient Advocate/Caregiver Pharmacist Prescribing Practitioner
Your Prescription was refused by which Pharmacy? *

CVS Walgreens Other
Do you have a copy of that policy or exchange?

Yes No
At which Pharmacy were you working when this event occurred?
Reason you were unable to fill prescription? *

Corp. Policy Other
Do you have a copy of that policy or exchange?

Yes No
Which best describes this situation? *

I am discouraged from writing prescriptions for COVID 19 therapeutics. Prescription written for patient was denied.
Discouraged by:

Hospital or SNF or Assisted Living Policy PPO, HMO, Insurance Policy Peer Physician or Employer Physician/Group
Name of Medical Group, Organization or Facility
Prescription denied by:

CVS Walgreens Other Pharmacy Hospital SNF or Assisted Living Facility
Name of Medical Group, Organization or Facility
Do you have a copy of that policy or exchange?

Yes No
Medication Prescribed:

Ivermectin Hydroxychloroquine Other
Do you have a copy of the prescription (if applicable): *

Yes No
Date of Prescription (if applicable):

Month Day Year
Date
You understand that you are submitting personal information related to your health that may be used in legal cases as a plaintiff. Your data will NEVER be shared, sold or rented. *

I understand
Picture of Prescription:

Cancel of
Policy or exchanges relevant to this event.

Cancel of
Brief Summary:
Should be Empty: