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Services
IV & PICC Line
Infusion/Transfusion
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Resources
Contact
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Call us Today
Date
Time
Facilities Name
Facilities Email
Caller's Name
Are You Calling from a Pharmacy?
Yes
No
Are You Placing an Order for a Facility?
Yes
No
What is the Facility Contact's Name?
Facility Phone Number
Extension Number
Facility Fax Number
Patient First Name
Patient Last Name
Room Number
Unit Number
Building Number
New Order
Re-Insert
Troubleshoot
What Happened to the Patient's Line?
Brief Description of Problem
Does the Patient Currently Have a Line?
Yes
No
What Type?
Peripheral
Midline
Picc
Single Lumen
Dual Lumen
Type of Order or Line
Peripheral
Midline
Picc
(if Picc) Does the Patient Have the Following
Pacemaker
Dialysis Port
Shunts
Fistula in Either Arm
Which Arm?
Mastectomies
Single or Double?
Access Port
Discontinue Line
DC Midline
DC Picc
Is the Patient Being Discharged?
Yes
No
When?
Troubleshoot
Is Line Infiltrated?
Yes
No
Is Line Occluded?
Yes
No
Medication Patient is Receiving or is to Receive
Is the Patient on Coumadin
Yes
No
What is the Patient's Last INR
Date
Is the Patient Leaving the Facility Today for any Appointments?
Yes
No
When Will the Patient Return?
Do you Have a Written Order for the Line Placement?
Yes
No
Picc- Is the Patient Competent to Sign a Consent?
Yes
No
Please download the Consent Form and have it signed, call us once the consent is signed so we can send it to a Nurse
We do not accept verbal consent from POA or Guardian- Please download Consent Form and 2 Facility Nurses can sign the Consent from once they receive verbal consent from POA or Guardian- Call us once the Consent is signed so we can send a Nurse
Send
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