Have you been unable to fill or refill a prescription for epinephrine auto injectors in the last three months due to a lack of adequate supply at your pharmacy?

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* 1. Have you been unable to fill or refill a prescription for epinephrine auto injectors in the last three months due to a lack of adequate supply at your pharmacy?

If you could not fill your prescription, were you able to obtain an alternate brand, and if so, which one?

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* 3. If you could not fill your prescription, were you able to obtain an alternate brand, and if so, which one?

What is the expiration date of the epinephrine auto injectors you obtained? (Check multiple boxes if you obtained more than one set of EAIs)

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* 4. What is the expiration date of the epinephrine auto injectors you obtained? (Check multiple boxes if you obtained more than one set of EAIs)

Comments?

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* 7. Comments?

OPTIONAL:  Name of person completing the survey

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* 8. OPTIONAL:  Name of person completing the survey

OPTIONAL:  Your email address

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* 9. OPTIONAL:  Your email address

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