CUHA Pharmacy Research Order Request Form

CUHA Pharmacy Research Order Request Form
Please submit this form to request that CUHA Pharmacy assist with obtaining pharmaceutical and veterinary products for research purposes.

Submission of this request does not guarantee approval. Requests will be reviewed to ensure appropriate procurement, documentation, storage, handling, and institutional compliance requirements are met prior to purchase.

Please allow a minimum of 2 business days for processing and pickup. We will communicate all purchasing or delivery concerns to the Requester.
Section 1: Requestor Information
Request Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Requestor Name:
Requestor Net ID:
Requestor Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Department/Laboratory:
Principal Researcher Name:
Researcher Email:
example@example.com
ezyVet Contact Number:
Account Number:
Accounting Contact Name:
Requested Date Needed:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

Section 3: Research Project information
Research Project Title:
Brief description of research project and intended use of requested product:
Section 4: Research Compliance Information for Administration to Animals
IACUC Status: (Choose one)
IACUC Protocol Number:
Ordering Clinician:
Patient Name:
Patient ID (if applicable):
Species:
Section 5: Storage and Responsibility
The requesting laboratory is responsible for ensuring appropriate storage conditions are available upon transfer of the product from CUHA Pharmacy.
Storage Location after transfer:

Section 1: Requestor Information