N.J. Admin. Code Tit. 13, ch. 39, subch. 14, app D
Pharmacist Visit Summary and Referral Template
Attention: You may customize this template by adding to it; however, you must retain all elements in this template.
Patient Name:________________ Date of birth:____/____/________
Date of visit: ___/___/___
Date hormonal contraceptive furnished (if applicable): ___/___/____
Please review this form with your primary care provider. If you do not have a primary care provider, you may follow up at _____________________ (insert name, address, and phone number of an appropriate and nearby medical clinic that provides primary and contraceptive care).
Recommended follow-up:
__________________________________________________________
Self-administered hormonal contraceptive furnished:
__________________________________________________________
Strength (if applicable): _____________ Quantity furnished: ______ Refills authorized: ______
OR
______ Pharmacist is not able to furnish a self-administered hormonal contraceptive to you because:
[] Pregnancy cannot be ruled out.
[] You may have a health condition than requires further evaluation.
[] You take medication(s) or supplements that may interfere with contraceptives.
[] Your blood pressure reading is _______/_____ (140/90 or higher) and you are not eligible for progestin-only pills because ______________________________________. Other
(e.g., intended use is not contraception)
Notes:________________________________________________
Each requires additional evaluation by another healthcare provider. Please share this information with your provider.
Pharmacist Name _________________________________________
Pharmacist Signature ______________________________________
Pharmacist License Number ________________________________
Pharmacy Name __________________________________________
Pharmacy Practice Site Permit Number ________________________
Pharmacy Practice Site Address ______________________________
Pharmacy Practice Site Phone Number _________________________
Information on reproductive rights, health care coverage and services, and other resources can be found at the New Jersey Reproductive Health Information Hub, http://www.nj.gov/health/reproductivehealth/.
Notes
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
Pharmacist Visit Summary and Referral Template
Attention: You may customize this template by adding to it; however, you must retain all elements in this template.
Patient Name:________________ Date of birth:____/____/________
Date of visit: ___/___/___
Date hormonal contraceptive furnished (if applicable): ___/___/____
Please review this form with your primary care provider. If you do not have a primary care provider, you may follow up at _____________________ (insert name, address, and phone number of an appropriate and nearby medical clinic that provides primary and contraceptive care).
Recommended follow-up:
__________________________________________________________
Self-administered hormonal contraceptive furnished:
__________________________________________________________
Strength (if applicable): _____________ Quantity furnished: ______ Refills authorized: ______
OR
______ Pharmacist is not able to furnish a self-administered hormonal contraceptive to you because:
[] Pregnancy cannot be ruled out.
[] You may have a health condition than requires further evaluation.
[] You take medication(s) or supplements that may interfere with contraceptives.
[] Your blood pressure reading is _______/_____ (140/90 or higher) and you are not eligible for progestin-only pills because ______________________________________. Other
(e.g., intended use is not contraception)
Notes:________________________________________________
Each requires additional evaluation by another healthcare provider. Please share this information with your provider.
Pharmacist Name _________________________________________
Pharmacist Signature ______________________________________
Pharmacist License Number ________________________________
Pharmacy Name __________________________________________
Pharmacy Practice Site Permit Number ________________________
Pharmacy Practice Site Address ______________________________
Pharmacy Practice Site Phone Number _________________________
Information on reproductive rights, health care coverage and services, and other resources can be found at the New Jersey Reproductive Health Information Hub, http://www.nj.gov/health/reproductivehealth/.