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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
STRESSE E DEPRESSÃO A noção actual de stresse ( stress ) vem de Hans Selye, um húngaro que viveu nos Estados Unidos da América e foi o autor de uma série de livros com um mesmo e elucidativo título: O Síndroma Geral da Adaptação (I, II, III, IV). Visivelmente preocupado com problemas de adaptação ao meio, Seley concebeu à partida o stresse como a reacção normal do organi
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