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Injectafer Femic carboxymaltose Injection

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Sex
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Allergies

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Therapy
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Ordering Provider

Ordering Provider

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Pre-Medication

Pre-Medication

Select each pre-medication ordered below. Then use the Pre-Medication dosing details field to specify the dose (mg) and route for each medication selected.
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Required Documentation

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Primary Diagnosis

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Primary Medication Order

Primary Medication Order

If necessary, Suite Life will round dose up/down according to payor guidelines.
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Medication Order (please select ONE)
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First Dose
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Line Use/Care Orders

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Adverse Reaction & Anaphylaxis Orders

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Ordering Provider Signature

Ordering Provider Signature

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By submitting your signature, the parties agree that this agreement may be electronically signed. The parties agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

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Please enter a 10-digit phone number (numbers only).
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Please enter a 10-digit phone number (numbers only).

Please sign your name in the area below

By submitting your signature, the parties agree that this agreement may be electronically signed. The parties agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

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