Allison Rose Foundation + Code Ana
Stock epinephrine is epinephrine prescribed to an entity, such as a school or restaurant, to be used in case of an allergy emergency. Code Ana is delighted to partner with the Allison Rose Foundation to help provide training.
How to Request a Prescription
1. Sign the agreement below in Part 1.
2. Complete the questions in Part 2.
Part 1: Sign the agreement.
(On your phone? Turn it landscape to see the Adobe form below.)
Part 2a: Complete this Epi Rx Request Form.
Are you a school in Alabama, Louisiana, Mississippi, Ohio, or Oklahoma and planning to request epipens from the EpiPen4Schools program? If yes, skip down to 2b. If no, complete this form. Non-school entities should also complete this form.
Epi Rx Request Form
Use this form to request a prescription for stock epinephrine. Not sure which device to request? Here is a list of the currently available devices.
Devices available for 66 pounds and up:
AuviQ 0.3 mg, EpiPen 0.3 mg, neffy 2 mg
Devices available for 33-66 pounds:
AuviQ 0.15 mg, EpiPen 0.15 mg, neffy 1 mg
Device available for 17.5-33 pounds:
AuviQ 0.1 mg
Part 2b: EpiPen4Schools - Alabama, Louisiana, Mississippi, Ohio, and Oklahoma.
Complete the form below. Your completed form will be share with our team for Dr. Hoyt's signature, after which you will receive your signed prescription to submit to EpiPen4Schools.
Trouble viewing it on your phone? Turn your device landscape.
The Fine Print
Although we do not dispense medications, we are committed to helping schools and non-schools entities obtain stock epinephrine and other life-saving medications. Please complete the forms above and reach out to us with any questions: epi-request@codeana.org.
