Hospital/Facility:	Select a hospital All Hawaiian PharMerica Facilities c/o Pharmerica Corporation Oahu Alvarado Hospital Canyon Springs Post Acute Center El Camino Los Gatos El Camino Mt. View Gilroy Healthcare and Rehabilitation Center Good Samaritan Hospital of San Jose Grant Cuesta Subacute and Rehab 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 Mission Skilled Nursing and Subacute Center Pacific Coast Manor Pacific Hills Manor Palo Alto SubAcute and Rehabilitation Center Paradise Valley Hospital PharMerica Corporation c/o PharMerica Monoclonal Antibodies Rehabilitation of the Pacific Saint Louise Regional Hospital - County Health System Sequoia 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):