University of Saskatchewan College of Pharmacy and Nutrition

Drug Information Service Healthcare Professional Form

SDIS drug information consultants will respond to both general and patient specific drug information questions from healthcare providers. Priority will be given to patient specific questions.

Drug information consultants check for questions at 9:00am, 11:30am and 3:00pm local time.

* Indicates required fields

1. Submittor Information

*Name:
Email:
Address:
*City:
Province:
Country:
Postal Code:
*Telephone:
Fax:
*Prefered method of corresponence:	Email Phone Postal Mail Fax
Response Required by:
*What is your profession:

2. If your question is patient specific, complete the questions in the following area with as much detail as possible. Otherwise, skip to question area 3.

Age:
Weight:
Sex:	Male Famale
Patient Medical Problems:
Current Medications:
Adverse effects/allergies:

3. Question

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Drug Information Service Healthcare Professional Form

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