Remdesivir
For urgent requests, acute care hospitals should complete this survey by COB at 5:00pm on Thursdays. This information will be provided to AmerisourceBergen on Fridays to reach out to hospitals to confirm ordering and shipments based on the state's allocation. Please note that completion of this form does not guarantee availability of remdesivir.

For more information, please visit: https://www.phe.gov/emergency/events/COVID19/investigation-MCM/Pages/factsheet.aspx
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Contact Name *
Contact Phone Number *
Contact Email Address *
Facility Name *
Shipment Site Address *
All quantities MUST be entered in vials. 1 case is 40 vials.
Estimated need of liquid remdesivir (# of vials) *
This is not a guarantee that you will receive this amount
Estimated need of lyophilized remdesivir (# of vials) *
This is not a guarantee that you will receive this amount
State Pharmacy License Number *
Site Procurement Contact Name *
Site Procurement Contact Phone Number *
Site Procurement Contact Email Address *
Additional Comments
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