Healthcare Drug Import Request

Healthcare Drug Import Request

Requestor (Prescriber or Authorized Agent):   License/ID No.:

Patient Information

Date of Birth:   Gender:

Phone:   Email:

Prescriber / Facility Information

Professional Title:   Contact Phone:

Prescriber Address:

Medication Details (to be imported)

Drug Name / Brand:   Active Ingredient:

Strength / Dosage Form:   Quantity Requested:

Manufacturer / Supplier:   Country of Origin:

Anticipated Start Date of Treatment:   Expected Duration of Supply:

Regulatory and Safety Declarations

Is the medication a controlled substance under applicable law? Yes No

By submitting this request, the prescriber certifies that the medication is medically necessary for the patient identified above, that the prescriber retains responsibility for lawful prescribing and administration, and that the requestor will comply with all applicable federal, state, and local laws governing importation, storage, dispensing, and recordkeeping. The prescriber further certifies that the information provided is complete and accurate to the best of their knowledge.

Attachments and Supporting Documentation

The following documents are submitted with this request (check all that apply):
Prescription or written order from prescriber
Patient identification
Informed consent for importation and use
Detailed treatment plan / medical records
Import permit or pharmacy authorization (if applicable)

Patient Authorization & Privacy

I authorize the release and disclosure of my health information and related documentation to entities and personnel necessary to effectuate the importation, customs clearance, transport, and clinical use of the requested medication. I understand that information disclosed may include my medical diagnosis, prescription information, and identifying information. I understand that my authorization is voluntary but necessary for importation processing.

Authorization expires on:

I acknowledge that importation may involve delays, customs inspection, and regulatory review. I release the prescriber, facility, and their agents from liability for lawful seizures, delays, or refusals by regulatory authorities provided they acted in good faith and in accordance with applicable law.

Additional Administrative Use

Proposed Shipping Method:   Estimated Arrival Window:

Certification

By signing below, I certify under penalty of perjury that the information provided on this Healthcare Drug Import Request is true and correct, that I have been informed of the intended use and known risks of the medication, and that I consent to the disclosure and use of my health information as described above for the purpose of importing the medication. I understand that this form does not guarantee approval of importation and that applicable regulatory authorities retain discretion to refuse entry or to require additional documentation.

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