Hospital/Facility:
Select a hospital
All California PharMerica Facilities c/o Pharmerica Corporation California
All Hawaiian PharMerica Facilities c/o Pharmerica Corporation Oahu
Alvarado Hospital
Canyon Springs Post Acute Center
El Camino Los Gatos
El Camino Mt. View
Good Samaritan Hospital of San Jose
Hazel Hawkins Memorial Hospital
Kaiser Permanente Redwood City Medical Center - ED
Kasier Permanente Redwood City Medical Center
Kasier Permanente Redwood City Medical Center- Outpatient
Kasier Permanente South San Francisco
Los Altos Subacute and Rehab
Menlo Park Surgical Hospital - Sutter Health
Mills Peninsula Burlingame - Sutter Health
Paradise Valley Hospital
PharMerica Corporation c/o PharMerica Monoclonal Antibodies
Regional Medical Center of San Jose
Rehabilitation of the Pacific
Saint Louise Regional Hospital - County Health System
Watsonville Community Hospital
If Pharmerica, name of the facility:
Your Name:
Patient Initials:
Patient Room Number:
Requested Procedure:
Contact Name:
Contact Phone Number:
If PICC insert, consent signed (Y or N):
DO NOT PLACE ORDER UNTIL YOUR PHYSICIAN TEAM HAS OBTAINED CONSENT.
Is this a renal/dialysis patient? (Y or N):
If this is a renal patient, get approval from nephrology before placing order.
Called nephrology for approval? (Y or N):