Telephone Order from Physician PDF

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Summary

A good form for getting an order from a doctor...

Description

78 Scott Dyer Road Cape Elizabeth, ME 04107 PH: (207)799-7332 F: (207)741-2751

NAME:

DOB:

ALLERGIES:

PHYSICIAN: DATE:

PHYSICIAN’S TELEPHONE ORDER

TIME:

PHYSICIAN’S SIGNATURE/DATE

FOR FACILITY STAFF ☐Faxed to pharmacy

☐Progress Note

☐Nordx Lab Slip

NOTED BY:

DATE:

CO-NOTED BY:

DATE:

☐Mobilex...