30013 D HR - Trillium Health Partners

PRE-PRINTED ORDERS for lymphoma
DHAP (Dexamethasone-High dose Ara-C (cytarabine)Platinol (cisplatin))
Weight _______________(kg)
REFER TO THE ALLERGY SCREEN IN MEDITECH FOR ALLERGY INFORMATION
Complete additional orders on page 3
Date:
Time:
PRESCRIBER SIGNATURE
THIS PPO MUST BE FAXED TO ONCOLOGY PHARMACY (ext.4486)
PRE-PRINTED ORDERS for lymphoma DHAP
(Dexamethasone-High dose Ara-C (cytarabine)-Platinol (cisplatin))
30013 D HR (October/2014) Page 1 of 8
R
EF
ER
EN
C
E
To complete the order form, fill in the required blanks and/or check the appropriate boxes.
To delete orders, draw one line through the item and initial.
E
R
30013 D HR (October/2014) Page 2 of 8
EF
ER
EN
C
THIS PAGE
IS BLANK
CONTINUE TO
NEXT PAGE
PRE-PRINTED ORDERS for lymphoma
DHAP (Dexamethasone-High dose Ara-C (cytarabine)Platinol (cisplatin))
PRE-PRINTED ORDERS for lymphoma
DHAP (Dexamethasone-High dose Ara-C (cytarabine)Platinol (cisplatin))
Weight _______________(kg)
REFER TO THE ALLERGY SCREEN IN MEDITECH FOR ALLERGY INFORMATION
Complete additional orders on page 5
Date:
Time:
PRESCRIBER SIGNATURE
THIS PPO MUST BE FAXED TO ONCOLOGY PHARMACY (ext.4486)
PRE-PRINTED ORDERS for lymphoma DHAP
(Dexamethasone-High dose Ara-C (cytarabine)Platinol (cisplatin))
30013 D HR (October/2014) Page 3 of 8
R
EF
ER
EN
C
E
To complete the order form, fill in the required blanks and/or check the appropriate boxes.
To delete orders, draw one line through the item and initial.
E
R
30013 D HR (October/2014) Page 4 of 8
EF
ER
EN
C
THIS PAGE
IS BLANK
CONTINUE TO
NEXT PAGE
PRE-PRINTED ORDERS for lymphoma
DHAP (Dexamethasone-High dose Ara-C (cytarabine)Platinol (cisplatin))
PRE-PRINTED ORDERS for lymphoma
DHAP (Dexamethasone-High dose Ara-C (cytarabine)Platinol (cisplatin))
Weight _______________(kg)
REFER TO THE ALLERGY SCREEN IN MEDITECH FOR ALLERGY INFORMATION
Complete additional orders on page 7
Date:
Time:
PRESCRIBER SIGNATURE
THIS PPO MUST BE FAXED TO ONCOLOGY PHARMACY (ext.4486)
PRE-PRINTED ORDERS for lymphoma DHAP
(Dexamethasone-High dose Ara-C (cytarabine)Platinol (cisplatin))
30013 D HR (October/2014) Page 5 of 8
R
EF
ER
EN
C
E
To complete the order form, fill in the required blanks and/or check the appropriate boxes.
To delete orders, draw one line through the item and initial.
E
R
30013 D HR (October/2014) Page 6 of 8
EF
ER
EN
C
THIS PAGE
IS BLANK
CONTINUE TO
NEXT PAGE
PRE-PRINTED ORDERS for lymphoma
DHAP (Dexamethasone-High dose Ara-C (cytarabine)Platinol (cisplatin))
PRE-PRINTED ORDERS for lymphoma
DHAP (Dexamethasone-High dose Ara-C (cytarabine)Platinol (cisplatin))
Weight _______________(kg)
REFER TO THE ALLERGY SCREEN IN MEDITECH FOR ALLERGY INFORMATION
E
To complete the order form, fill in the required blanks and/or check the appropriate boxes.
To delete orders, draw one line through the item and initial.
Date:
30013 D HR (October/2014) Page 7 of 8
R
EF
ER
EN
C
Additional Orders
Time:
PRESCRIBER SIGNATURE
THIS PPO MUST BE FAXED TO ONCOLOGY PHARMACY (ext.4486)
PRE-PRINTED ORDERS for lymphoma DHAP
(Dexamethasone-High dose Ara-C (cytarabine)Platinol (cisplatin))
E
R
30013 D HR (October/2014) Page 8 of 8
EF
ER
EN
C
THIS
PAGE
IS BLANK
PRE-PRINTED ORDERS for lymphoma
DHAP (Dexamethasone-High dose Ara-C (cytarabine)Platinol (cisplatin))

Download Report