Name:
Address:
Postal Code:
Infusion Therapy Referral Form
Phone: 800-263-3877
Fax:
855-352-2555
Height:
Date of Birth:
Phone:
HCN:
Version Code:
(mandatory)
Blood Pressure:
Yes
No
Allergies:
Line Type
F
Other Diagnosis:
Telehomecare:
Yes
Metastatic Spread:
If Cancer Diagnosis or a
Life Limiting Illness
M
If your patient is in hospital please
indicate hospital site:
Primary Diagnosis:
Weight:
Diabetic:
Sex:
No
Yes
Related to:
COPD
No Describe:
Ongoing Treatment:
Palliative
Curative
Anticipated Prognosis:
<6 months
6-12 months
Peripheral
Midline
PICC
Insertion date:
Uncertain
Hickman
Port
SC
# of lumen(s):
Alternative routes discussed
1st Dose Given: Yes
CHF
No
Yes
No
, If YES, indicate date and time given:
1st Community Dose: indicate date and time:
IV Medications/
Hydration
Name of Medication:
Dosage:
Route:
# of Doses Required:
Frequency:
# of Days of therapy in Community:
Name of Medication:
Dosage:
Route:
# of Doses Required:
Frequency:
# of Days of therapy in Community:
For hydration, specify reason:
SPECIFIC PHYSICAN ORDERS: (please state)

Infusion/dressing protocols per line type

Saline Flush:
or

Heparin Flush – specific Physician/Nurse Practitioner order required:

Specify lab orders if required:

Other treatment/therapies/services:
per nursing agency protocol
Note: If unable to restart – patient to Emergency Department
Exceptional circumstances may result in a missed dosage of medication
Unless otherwise indicated, the Community Care Access Centre may determine frequency of visits, arrange for teaching of
patient/caregiver(s)/other regulated staff/reliable person(s).
Ordering Physician /Nurse
Practitioner
Print Name:
Signature:
Date:
CECCAC-CM-625 (01/16)
CPSO/
CNO#
Contact Information for Ordering
Physician
Telephone:
Fax:
After Hours:
Lab results to be sent to
Physician/Nurse Practitioner
Name:
Fax: