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):