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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)
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Geophysical Research Abstracts, Vol. 9, 04712, 2007SRef-ID: 1607-7962/gra/EGU2007-A-04712© European Geosciences Union 2007 Characterization of mortars used since baroque period on altar of St. Jacob Church (Ljubljana, Slovenia) S. Kramar (1), B. Mirtiˇc (2), M. Gregerová (3) (1) Institute for the Protection of Cultural Heritage of Slovenia, Restoration Center, Slovenia. (2) University of

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