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

Street Address

Street Address Line 2

CityState

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

PatientPatient Advocate/CaregiverPharmacistPrescribing Practitioner
Your Prescription was refused by which Pharmacy?*

CVSWalgreensOther
Do you have a copy of that policy or exchange?

YesNo
At which Pharmacy were you working when this event occurred?
Reason you were unable to fill prescription?*

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

YesNo
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 PolicyPPO, HMO, Insurance PolicyPeer Physician or Employer Physician/Group
Name of Medical Group, Organization or Facility
Prescription denied by:

CVSWalgreensOther PharmacyHospitalSNF or Assisted Living Facility
Name of Medical Group, Organization or Facility
Do you have a copy of that policy or exchange?

YesNo
Medication Prescribed:

IvermectinHydroxychloroquineOther
Do you have a copy of the prescription (if applicable):*

YesNo
Date of Prescription (if applicable):

MonthDayYear
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:

Cancelof
Policy or exchanges relevant to this event.

Cancelof
Brief Summary:
Should be Empty: