Oral Oncology Donation Request Form

Oral Oncology Donation

Request Policy

Effective April 24, 2025

Dispensing of oral oncology medications provided by SafeNetRx must be overseen by a licensed oncologist. Please fill out the form below to receive the requested medication(s). Your order will not ship until this form has been completed. Thank you!

Prescribing Oncologist (Full Name):
Prescribing Information

Prescribing Oncologist's State License or NPI number:

Prescribing Oncologist's Phone Number:

If the listed prescriber is NOT an oncologist, please explain the circumstances. List any oncologists that your care team will collaborate with for the patients treatment:

Please check the box below to attest to the active involvement of an oncologist in the patient's treatment:

Please indicate whether or not the patient has received the requested medication before:


Dispensing Requirements
Dispensing partners are responsible for counseling patients on pertinent drug information prior to dispensing. Dispensed medication must meet state board of pharmacy labeling requirements and include the orginal package insert or FDA approved prescribing information with each fill. See below for patient labeling resources.
Please check the box below to indicate that you have read and understand the dispensing requirements:


Documentation Requirements
Dispensing partners are required to gather and document pertinent information prior to dispensing oral oncology medications to a patient including, but not limited to, treatment regimen or protocol and relevant labs.
Please check the box below to indicate that you have read and understand the documentation requirements:


Contact Information
Name of Individual Requesting Medication:

Email of Individual Requesting Medication:

Phone Number of Individual Requesting Medication:

Patient Labeling Resources

SafeNetRx is a 501(c)3 non-profit organization with a mission to solve medication inequity through responsible collection and distribution of donated medicines.

SafeNetRx

1500 SE 19th St, Ste 530, Grimes, IA 50111

Phone: 1-866-282-5817
Fax: 515-327-5422
Email: repository@safenetrx.org

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Drug Donation Repository

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Oral Oncology Donation

Request Policy

Effective April 24, 2025

Prescribing Information

Dispensing Requirements

Documentation Requirements

Dispensing partners are required to gather and document pertinent information prior to dispensing oral oncology medications to a patient including, but not limited to, treatment regimen or protocol and relevant labs.

Contact Information