New NDC Request — Medical Center Public Site

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Medication Drug name

Dosage Form Tablet, capsule, syringe, suspension, etc

Medication Strength mg, g, etc

Medication Volume Total volume of product

Medication Concentration mg/mL, g/mL, %, etc

Product NDC For products without and NDC, please enter the UPC code.

Refrigerated Item Please check box if this is a refrigerated item. These items should be left in the "Waiting for Pharmacy IT" bin in the refrigerated once ticket is completed.

Comments Please enter any information that may be helpful.

For Supply Chain Use ONLY

Why is this product being ordered?