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Please fax back back to: 713-973-0805
DESTINATION (Required): _____________________ Length of Stay: Departure Date: _______
_____________________ MEDICATION/KIT/SUPPLY REQUESTED:
MED KIT: ______Basic _____Full
* Hydrocodone/Acetaminophen 5/500
Cost Center/PO/SAP#
(Global Santa Fe Employees must indicate Cost Center & SAP #)
PATIENT INFORMATION UPDATE:
NEW MEDICAL PROBLEMS:
CURRENT MEDICATIONS:
Temazapam
* Zolpidem: Ambien CR:
ALLERGIES: ______N ______Y
CHRONIC DISORDERS:
* OTHER: __________________________
__________________________
MEDICATION DELIVERY/PICK-UP
*CONTROLLED SUBSTANCES REPORT
___ Own Pharmacy: ________________________________ ___ Client picking up meds here: Date: ______Time:_____
___ Deliver ** meds to:
____________________________ Date: ______Time:_____ **Delivery Charge depends on destination
___Bill Company: __________________________________ For Internal Use Only:
Non-MD Staff: MAKE SURE ABOVE TRIP DEPARTURE DATE IS COMPLETED BEFORE GIVING TO M.D
How soon does patient need refill?_______________________________________ URGENT?
Outstanding Balance $: Patient
Business Staff:
Given above BALANCE, OK to refill med ___Y___N, OR have patient settle balance
If patient using ABx Pharmacy, should we give med prior to settling Outstanding Balance? MD Section: See above Business Staff Section Refill? Y
MUST MAKE APPT:
M.D. Initials:
___________________________________________________________________________________________________________ If REFILL answer is NO (Business or Pharm/Nursing Staff), write comments or discuss with physician.
Nursing: Reviewed By:
If Rx denied, CONTACTED:
Was a copy of request given to Pharmacist?
N, Rx called in to:
COMMENTS:
N FILLED By:
___Provide Return Office Visit Form to Physician
___ Record in IMC TRACKING LEDGER
under Refills _____ Initials (done)
E:\intranet\source\Pharmacy Refill Request.doc

Source: http://www.traveldoc.com/wp-content/uploads/2013/02/Pharmacy-Refill-Request.pdf