Plan B Pharmacy Script and Form

Choice Action Center

Plan B Pharmacy Script and Form

Thank you for collecting information about the availability of Plan B® in your community! Below is a sample script you can use as a guide when calling pharmacies in your community. While you are on the call, please record the information you collect in the form below.

Sample Script

May I speak with the pharmacist? (If possible, please record the name of the pharmacist with whom you speak.)

Do you carry Plan B®, the "morning-after" pill?

IF YES: Great! How much does it cost?

IF NO: Is Plan B® out of stock or do you not carry it?

Thank you so much.

Plan B® Pharmacy Provision Form

Your First Name:
Your Last Name:
Your Email:
Pharmacy Name:
Pharmacist Name:
Street Address:
City:
State:
Zip:
Phone Number:
Date of Call/Visit:
Time of Call/Visit:
Do they stock PlanB®?	Yes No
Cost:
Comments:

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