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Use tab to navigate through the menu items.
Let Us Do the W
ork for You (LUD
)
Patient and/or alternate contact will be
contacted by a patient care
advocate to help the patient get set up with a participating phar
macy.
Patient Name
Patient Phone
Patient Email
Patient Date of Birth
Patient Address
City
State
ZIP
Patient Participated in Recent Zoom / Virtual Presentation?
Yes
No
Pharmacy Name
Pharmacy Phone
Are you currently filling at this pharmacy?
Yes
No
Pharmacy Address
City
State
ZIP
Which ScriptAbility formats are you interested in?
ScripTalk (Talking Labels)
ScriptView (Large Print Labels)
Braille Labels
Other accommodations (Spanish, delivery, mailed) :
Name
Agency
Phone
Email
Submit
Thanks for your information!
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