725 Welch Road, Palo Alto 94304 Date: Patient: FIN: DOB: Appt Date & Time: MRN: NEW ONSET DIABETES (NOD) PACK - Medications and Supplies MEDICATIONS * [√ ] Humalog Insulin (Lispro) Vial 10 mL Sig: As directed RFs: 0 * [√ ] Lantus Insulin (Glargine) Vial 10 mL Sig: As directed RFs: 0 1 kit [√ ] Glucagon Emergency Kit (1mg) Sig: As directed RFs: 0 TEST STRIPS [√ ] Contour Next Test Strips # 300 or approved quantity Sig: As directed RFs: 0 LANCETS AND DEVICE [√ ] One Touch Delica Lancets 33G # 300 or approved quantity Sig: As directed RFs: 0 One Touch Delica Lancing Device [√ ] #1 Sig: As directed RFs: 0 SYRINGES (indicate which syringe scale) * [ ] BD Insulin Syringes Ultra-Fine Short 6mm (1/2 unit scale) 30 unit # 200 or approved quantity Sig: As directed RFs: 0 * [ ] BD Insulin Syringes Ultra-Fine Short 8mm (1 unit scale) 50 unit # 200 or approved quantity Sig: As directed RFs: 0 OTHER SUPPLIES [√ ] Urine Ketone Test Strips # 50 Sig: As directed RFs: 0 * [√ ] Sharps Container 1 container Sig: As directed RFs: 0 Prescriber's Name: [ ] Tandy Aye, M.D CA license: A95092 [ ] [ ] Laura Bachrach, M.D. CA license: G36802 _____________________ M.D. [ ] Bruce Buckingham, M.D. CA license: G25563 CA License _____________ [ ] Caroline Buckway, M.D. CA license: A60707 Prescriber Signature: [ ] Brian Feldman, M.D. CA license: A84899 [ ] E. Kirk Neely, M.D. CA license: G55037 [ ] Avni Shah, M.D. CA license: A83856 Email dispensing issues to **: [ ] Darrell Wilson, M.D. CA license: G38484 DL‐LPCH‐[email protected] [ ] Margaret Atkins, M.D. CA license: A131537 [ ] Sejal Shah, M.D. CA license: A103168 [ ] Stephanie Crossen, M.D. CA license: A125418 Requesting CDE: [ ] Hilary Seeley, M.D. CA license: A121385 [ ] Daniel DeSalvo, M.D CA license: A121730 [ ] Elizabeth Kunselman, N.P. NPI#: 1821194051 Phone number: [ ] Kim Clash, P.N.P. NPI#: 1609903855 [ ] Netra Punjabi, P.N.P. NPI#: 1255627659 Fax Order Form to 650-497-8974 Any questions/concerns can be directed to Minh Tran, PharmD [email protected] Outpatient Pharmacy (1st floor) Melissa Yee, PharmD [email protected] Phone: 650-724-5124 * Must be ready for AM pick-up (others can be ready for PM pick-up) ** On-call pediatric endocrine fellow can also be contacted via operator Pharmacy Network ‐‐> Private ‐‐> New Onset Diabetes Program (3.21.14)