Academic Detailing Request Form
First Name
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Last Name
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Provider Type
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Pharmacist
Prescriber
Other
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Please fill out at least one of the contact methods below
Email
Phone Number
Phone
Work Address
Pharmacist Topics of Interest
Buprenorphine Dispensing
Naloxone Dispensing
Opioid Safety (ex. dangerous drug combinations, storage, disposal)
Review of the Prescription Drug Monitoring Program (PDMP)
Harm Reduction
Prescriber Topics of Interest
Start Low and Go Slow
Use of Non-Opioid Treatment
Review of the Prescription Drug Monitoring Program (PDMP)
Opioid Safety (ex. dangerous drug combinations, safe storage, disposal)
Offer Treatment or Referral
Co-Prescribing or Dispensing Naloxone
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