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)
E:\intranet\source\Pharmacy Refill Request.doc
REVIEW ARTICLE Walaiorn Pratchyapruit, M.D. Patchnee Tohtubtiang, M.D. Institute of Dermatology ■The purpose of the authors is to familiarize the logic inflammatory cells namely: eosinophils, polymor-readers with the principles that master the diagnosisphonuclear cells, mast cells, macrophages involve inand management of bullous pemphigoid (BP), itspathophysiologic process
SUSPENSIÓN. NO PROCEDE CONTRA ACTOS NEGATIVOS CON EFECTOS POSITIVOS (LEY FEDERAL DE COMPETENCIA ECONÓMICA). El artículo 124 de la Ley de Amparo dispone que para el otorgamiento de la suspensión de un acto de autoridad deben concurrir los siguientes requisitos, que a saber, son: 1. Que se solicite la suspensión; 2. Que no contravenga disposiciones de orden público ni se ocasione perjui
Please fax back back to: 713-973-0805