Medication Donation Form

Thank you for donating meds with RemediChain!

Submission of this form meets the requirements of the Prescription Donation Repository Program established by the Kevin Clauson Drug Donation Act, Tennessee Code Annotated, Title 63, Chapter 10. All participants in the program must act in good faith and agree to make donations in accordance with the Act. This form automatically filters for eligible medication donations in accordance with Tennessee law and our internal pharmacy standards, which prioritize the safety of the patients we serve. Eligible donations are: unopened, unexpired, in the original manufacturer's packaging; and in the form of capsules, tablets or inhalers. Blister packs are eligible, as long as unused doses remain sealed. Loose pills cannot be donated, even those in pharmacy-issued brown bottles. We cannot accept controlled substances, birth control or refrigerated medications. Although we currently can only rescue capsules, tablets, and inhalers, we hope to expand to other dosage forms in the future.

"*" indicates required fields

URL

This field is for validation purposes and should be left unchanged.

First Name*

Last Name*

Phone Number*

Email Address*

What is your relationship to the person initially prescribed the medication you'd like to donate?

Patient (the meds are yours)

Spouse/Partner

Parent

Child

Family member (non-immediate) or friend

Professional Caregiver

Hospice staff

Other health care provider (navigator, physician, clinic/hospital staff, etc.)

Prefer not to say

Shipping Address*

RemediChain can legally accept donations of unused medications from anywhere in the United States of America. Including your shipping address on this form ensures our compliance and, ultimately, the safety of the donated medications being shared with other patients. We'll never share or sell your personal contact information.

Street Address City State ZIP Code

What is the dosage form of the medication you'd like to donate?*

Medication Name*

Brand names are acceptable. If you have a generic, you can put the specific medication name as written on the prescription label. If it says "generic for" with a brand name, you can write that too.

Dose/Strength*

This information is usually available on the prescription label. For example, a single pill may be 4mg. If you're not sure, just write "unsure."

How much do you have?*

Here, we're looking for the number of pills/units.

Is this medication a controlled substance?*

Yes

Does this medication require any special handling (for example, refrigeration)?*

Yes

Is the medication unexpired, with at least six months until its expiration date?*

Yes

Is the medication in its original manufacturer's packaging (no brown pharmacy bottles or other alternate containers)?*

Yes

Is the medication in a SEALED package (foil-sealed, blister packs, etc.)?*

Yes

How did you hear about RemediChain?

Check all that apply.

Social Media (Facebook, YouTube, LinkedIn, etc.)

Health Care Provider or Social Worker

Friend/Family Member

News Story

Search Engine (Google, etc.)

Message Board (Reddit, etc.)

ChatGPT

Unsure

Will you help us with some additional information for research purposes?

The following questions are for research purposes only and will not be shared. Any answers you provide will not be connected to your name or other identifiable information, nor will they impact the eligibility of your medication donation. Our goal in collecting this information is to continually improve medication reclamation to benefit patients across the country. Please answer to the best of your ability.

Will you help us understand why this medication is unused and available for donation?

The patient had negative side effects with this medication.

The patient passed away before using the medication.

The patient's health issues have resolved and the medication is no longer necessary.

The patient's health condition changed, requiring a different medication or dosage.

The pharmacy filled the prescription with a multi-month supply, and the patient did not need all of it.

The patient did not take the medication as often as prescribed and wound up with more than necessary.

Error (by the patient, the prescriber or the pharmacy)

Other

Please explain your selection of "other" in the previous question.

Was the patient under hospice care?

Yes

Unsure

How soon after the last fill did the patient pass away?

Within 7 days

8-30 days after the fill

31-90 days after the fill

More than 90 days after the fill

Unsure

What led to the improvement?

Surgery/Procedure

Completed Short-Course Therapy

Lifestyle/Rehab

Spontaneous Resolution

Other

Please explain your selection of "other" in the previous question.

Who initiated the medication change?

Prescriber

Patient

Insurance/Pharmacy Policy

Unsure

Why was the therapy changed?

Select between 1 and 2 choices.

Lack of effect (medication was not working)

Negative side effects

Drug interactions

New contraindication (for example, pregnancy, low eGFR)

Formulary/coverage change

Cost

Convenience/adherence

Other

How severe were the side effects?

Mild (noticeable but did not interfere with daily life)

Moderate (occasionally interfered with daily life, patient sometimes had to make accommodations)

Severe (seriously impacted day-to-day life)

When did the side effects begin after the patient began taking the medication?

Within the first week

Weeks 2-4 after starting the medication

More than a month after starting the medication

Unsure

What type of side effects did the patient experience?

Gastrointestinal (digestion/stomach)

Neurologic (brain-related)

Cardiac (heart)

Dermatologic (skin)

Musculoskeletal (muscle/bone)

Psychiatric (mental health)

Other

Unsure

What type of error occurred with the medication?

Patient error (forgot to let pharmacy know of coming med change, forgot to notify of an allergy, etc.)

Pharmacy error

Prescriber error

Shipping error

Other

Unsure

What made it difficult for the patient to take the medication as prescribed?

Where was this prescription originally filled?

Retail Pharmacy (Walgreens, CVS, locally owned pharmacy, etc.)

Mail-Order Pharmacy

Specialty Pharmacy

Hospital/Clinic

Unsure

Was the prescription set to be auto-refilled?

Yes

Unsure

Did the patient's insurance plan fill this medication in 90-day increments?

Some plans may require these intervals, while others incentivize it through lower prices on 90-day versus 30-day fills, for example.

Yes

Unsure

The patient is not covered by health insurance.

Did the patient start taking this medication?

Consider whether the patient ever took the medication. If the amount to be donated was unused because it was refilled with more than the patient needed, the answer is still yes.

Yes, at least one dose.

Unsure

When did the patient stop taking the medication?

This question relates to if the patient stopped voluntarily (due to side effects, for example). If the medications are unused due to death or required change (physician changed meds after the fill due to disease progression, allergic reaction, etc.) please choose "not applicable."

Within 7 days of starting

8-30 days after starting

31-90 days after starting

More than 90 days after starting

Unsure

Not applicable

How confident are you in your answers to the research-specific questions?

Very

Somewhat

Not at all

May we contact you if we need clarification on the research questions?

Yes

Please let us know how you prefer we contact you, if necessary.

We're looking for a phone number, an email address, or both!