ScriptPro Drug Information Form

ScriptPro ® Drug Information Form

Complete this form to add or adjust products in database.
This form is for data submission only; use printable form to submit a sample.

Pharmacy Name:	*
Completed By:		Email Address:	*

Status:	New - Drug record or image is not present.
	Correction - Drug record information has an error.
	Improvement - Drug image present is correct, but a change would improve the appearance.
	Different Appearance - Drug in bottle is different than the drug image present.
Comments:

Please check one of the following:

NDC

DIN

OTC/Dietary Supplement

Pharmacy Specific Drug

Please provide detailed drug information below:

NDC/DIN:	(exactly as it appears on bottle)
Stock Bottle Barcode/UPC:	(10 digits as on bottle)
Brand Name (only if branded):
Generic Name:	*
Distributor:	*
Strength/Unit:	* (ex. 300/100 mg)
Dose Form:	* (specify if EC/ER)
Stock Bottle Size:	*
Units/12 Dram:	(Kerr 12/OB 13 dram 90% full)

Please complete below information on tablet/capsule appearance if applicable.
Color:		Color Pattern:
Shape:		Scoring:
Markings:
* Required field