Enter Date Here
Name of Retail Pharmacy Manager in Charge
Their Title
Retail Pharmacy Name
Pharmacy Location Address
City, State, & Zip Code
To Whom It May Concern:
We recently became aware that some pharmacy technicians in the U.S. aren’t always
adequately trained or regulated to compound medications or fill prescriptions (for
more info go to www.emilyjerryfoundation.org).
Please be advised that from this date forward any and all prescription medications
filled at your retail pharmacy location for insert patient name should to be filled
only by a registered pharmacist with the proper certifications and training.
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 pharmacy or our welfare.
By signing and dating this document below, your retail pharmacy location 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 pharmacy manager in charge
___________________________________________________________
Signature of the patient or legal guardian