Horizon Healthcare Services

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For physician or nursing agency use only.
Please fill out form below completely. If you have any questions, please call us at
800-848-3204 or 717-544-3590.

*Patient Name:
*E-mail:
Height:	ft. in.	Weight: lbs.
Allergies:
Diabetes: Mellitus: Yes No - Type:
Conscious Impaired: Yes No
Patient/Caregiver able to Learn: Yes No

Prescription #1:
Ordering Physician:
Dx:
Infectious Organisms:
Route:	IV IM IV Push Tube Feeding SQ
Dose/Frequency
Duration: (include stop date)
Next Dose Due:
Last Dose Given:
First dose in Md Office/Hospital:	Yes No

Prescription # 2:
Ordering Physician:
Dx:
Infectious Organisms:
Route:	IV IM IV Push Tube Feeding SQ
Dose/Frequency
Duration: (include stop date)
Next Dose Due:
Last Dose Given:
First dose in Md Office/Hospital:	Yes No

Prescription # 3:
Ordering Physician:
Dx:
Infectious Organisms:
Route:	IV IM IV Push Tube Feeding SQ
Dose/Frequency
Duration: (include stop date)
Next Dose Due:
Last Dose Given:
First dose in Md Office/Hospital:	Yes No

Nutritional Therapy monitoring provided by:
Lancaster General Hospital Dietician
Reading Hospital Dietician
Other - If "Other" fax the following to Horizon Healthcare Services:
• Discharge Summery • History and Physical • Medication List
Admission Activity:

Select One:

Gravity Pump

Name of Pump:

Type of Access: (Check all that apply)
Peripheral:
	Comments:
Central:
	Type:
	Date Inserted:
PICC:
	Brand/Size/ Length:
	Date Inserted:
	Arm Circumference:
Port:
	Type:
	Date Inserted:
	Lot #:
Enteral
	Type:	PEG NG G-TUBE Other:
	Date Inserted:
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