Agency Contact Name:*

PEMS EMS AGENCY FORMULARY RESUPPLY REQUEST FORM

PEMS has purchased Class VI medications that can be distributed to licensed non-commercial EMS agencies in the PEMS Region.  This is made possible through the generous financial assistance from Sentara Cares, Riverside Health, Children’s Hospital of the King’s Daughters, and the Dominion Energy Charitable Foundation.  Only pre-established authorized persons from their respective agencies may complete and submit a request to resupply Class VI medications from the PEMS Regional Formulary during the first two weeks of each month.  The medications must have been used by the licensed EMS Agency or expired during the month preceding the request. 

Medications will be resupplied on a one-for-one basis

Please complete the Formulary Resupply Request below.  Items with an asterisk are required.

Agency:*
VA EMS Agency License Number:*
VA CSR Registration Number*
Delivery Address:*
E-mail:*
Phone Number of Individual Completing Request:*
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By clicking "I Agree" I attest that I am authorized by my agency to complete this medication resupply request on behalf of the EMS Agency indicated above and have secured appropriate approval. I understand that this request does not guarantee that I will receive the amount requested. Supplies will be distributed in a timely manner based on the availability of medications at any given time. *
ADENOSINE SDV 3MG/ML 2ML - Quantity Requested
ALBUTEROL SULFATE VL NEB 0.08 - Quantity Requested
AMIODARONE VL 50MG/ML 9ML - Quantity Requested
ASPIRIN TAB CHEW 81MG 36/BT - Quantity requested
ATROPINE SULFATE SYR 0.1MG/ML - Quantity Requested
CALCIUM CHLORIDE SYR 10 100MG - Quantity Requested
DEX IVSOL 10 250ML - Quantity Requested
Diphenhydramine 50mg/mL, 1ml V - Quantity Requested
EPINEPHRINE ABJT 0.1MG/ML 10M - Quantity Requested
EPINEPHRINE AMP PF 1MG/ML 1ML - Quantity Requested
EPINEPHRINE MDV 1MG/ML 30ML - Quantity Requested
FUROSEMIDE VL 100MG/10ML - Quantity Requested
GLUCAGON VL 1MG/ML NOVA+ - Quantity Requested
HALOPERIDOL LACTATE SDV 5MG/M - Quantity Requested
IPRATROPIUM BROMIDE SOL 0.020 - Quantity Requested
KETOROLAC TROMETHAMINE SDV 30 - quantity Requested
LIDOCAINE HCL SYR DISP 2 100M - Quantity Requested
MAGNESIUM SULFATE 5G/10ML - Quantity Requested
NiITROGLYCERIN SUBLINGUAL TABLETS, USP 0.4 mg/tablet - (25 Tablets Vial) Quantity Requested
NOREPINEPHRINE BITARTRATE SDV - Quantity Requested
ONDANSETRON INJECTION, USP 4mg/2 ml (2 mg/ml) Quantity Requested)
ONDANSETRON ODT TAB 4MG UD - Quantity Requested
SODIUM BICARBONATE SYR 8.4 1M - Quantity Requested
SOLU-MEDROL VL AOV 125MG/2ML- Quantity Requested

I understand that this request does not guarantee that I will receive the amount requested. Supplies will be distributed based on a variety of factors including  critical need and individual medication supply availability. We will make every effort to distribute emergency supplies equitably and in a timely manner.

**

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