Enter Date Here
Name of Administrator in Charge
Their title
Facility’s Name
Facility’s Address
City, State, & Zip Code
Dear Administrator in Charge’s Name,
We recently became aware that some pharmacy technicians in the U.S. aren’t always
adequately trained or regulated to formulate intravenous solutions, compound
medications, or fill prescriptions (reference www.emilyjerryfoundation.org).
With regards to medications prescribed during the entire course of treatment at
insert name of facility, we insist that only a registered pharmacist should prepare
any and all medications for insert patient name. We request that you agree to
these terms prior to the beginning of inpatient or outpatient treatment.
This includes the compounding and preparation of ALL intravenous (IV)
medications, as well as the dispensing of all solid medications from your internal
clinical pharmacy or outpatient pharmacy.
Thank you for your cooperation. This request is being made in order to lower the
probability of a preventable medication error or miss-fill from occurring to insert
patient name—which would not be good for either your facility or our welfare.
By signing and dating this document below, your facility agrees to fully adhere to
these very reasonable terms and conditions for the aforementioned individual.
Please keep this letter on file, and make note in your computer.
Signature of Administrator in Charge
Signature of the patient or legal guardian