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/.
N.J. Admin. Code Tit. 13, ch. 39, subch. 14, app D