Pharmacies can record the destruction of free trial Product and request replacement of non-dispensed units for Program-approved reasons (e.g., expired or damaged Product).
To process a request, select the designated pharmacy and identify the applicable unit by serial number. Then select the reason for the request, indicate whether the Product has been destroyed, and specify whether a replacement unit is requested to replenish inventory.
| Product / strength | NDC | Replacement Qty |
|---|
| Product | Units for Destruction | Reason(s) | Already Destroyed | To Be Destroyed |
|---|
By signing below, I attest that:
Under 21 CFR Part 11, an electronic signature must include at least two distinct identification components. On the online ordering portal, your electronic signature is executed through secure, multi-factor authentication credentials unique to your account. For the mobile application, your signature is captured as a digital representation of your handwritten signature recorded directly via your mobile device.
I certify that I am the person named above. I understand that the information presented above constitutes this electronic signature, which is the legal equivalent of my handwritten signature and will be accepted as the same in a court of law or before any federal or state regulatory agency with appropriate jurisdiction.
Please complete the form below to submit your order.
| Order # | Order Type | Product | Order Qty | Submitted | Status | Pharmacist | Notes (Ref #) |
|---|
Replacement orders and destruction records are visible to all pharmacists enrolled at this location. The Notes column references the originating destruction record number.