Name:
Address:
Postal Code:
Sex:
Narcotic Infusion Therapy Referral Form
Date of Birth:
Phone:
Phone: 800–263-3877
HCN:
Version Code:
Fax:
Ordering Physician (PRINT):
(mandatory)
855-352-2555
Primary Diagnosis
M
F
If your patient is in hospital please indicate
hospital site:
Diabetic:
Yes
No
Height:
Allergies:
Weight:
Blood Pressure:
Other Diagnosis
Pertinent to Care
Metastatic Spread:
Yes
No Describe:
If Cancer Diagnosis
Ongoing Treatment:
Palliative
Curative
or a Life Limiting
Illness
Anticipated Prognosis:
<6 months
6-12 months
Medication
Morphine
Hydromorphone
Uncertain
Other:
Added Meds
Concentration
mg/mL
(Note: The higher the concentration, the smaller the infusion volume to preserve subcutaneous routes)
sc
Route
Infusion Rate
Other:
(If IV, basal rate vol. must be 0.5 mL/hr)
Minimum mg/hr:
Breakthrough Bolus
Minimum
Doses
q 15
Breakthrough Bolus
q
Interval
Reservoir Size
Total Quantity of
Reservoirs
OTHER INFORMATION:
mg
min prn
min prn
Maximum
mg/hr:
Starting
mg/hr
Maximum
mg
Starting
mg
Maximum
doses/hr
Maximum
doses/hr
100 mls
Other:
10 (ten)
Other:
ml
Dispense at
each time
2 (two)
Other:
Unless otherwise indicated, the Community Care Access Centre may determine frequency of treatment, arrange for teaching
of patient or other reliable person and/or request assessment from other Community Care Access Centre disciplines.
Ordering Physician /Nurse
Practitioner
Print Name:
Signature:
Date:
CECCAC-CM-630 (01/16)
CPSO/
CNO#
Contact Information for Ordering
Physician
Telephone:
Fax:
After Hours:
Lab results to be sent to
Physician/Nurse Practitioner
Name:
Fax: