Adult Ambulatory Infusion Order Form - Cho Intravenous Immune Globulin (Ivig) Page 4
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4Oregon Health & Science University
Hospital and Clinics Provider’s Orders
ACCOUNT NO.
ADULT AMBULATORY INFUSION ORDER
MED. REC. NO.
NAME
CHO:INTRAVENOUS IMMUNE
BIRTHDATE
GLOBULIN (IVIG)
Page 4 of 4
Patient Identification
ALL ORDERS MUST BE MARKED IN INK WITH A CHECKMARK ( ) TO BE ACTIVE.
B
, I
:
Y SIGNING BELOW
REPRESENT THE FOLLOWING
I am responsible for the care of the patient (who is identified at the top of this form);
I hold an active, unrestricted license to practice medicine in:
Oregon
(check
box that corresponds with state where you provide care to patient and where you are currently licensed.
Specify state if not Oregon);
My physician license Number is #
(MUST BE COMPLETED TO BE A VALID
PRESCRIPTION); and I am acting within my scope of practice and authorized by law to order Infusion of
the medication described above for the patient identified on this form.
OLC Central Intake Nurse:
Ph: 971-262-9645 (providers only)
Fax: 503-346-8058
Please check the appropriate box for the patient’s preferred clinic location:
INFUSION CLINIC LOCATIONS
Beaverton
NW Portland
OHSU Knight Cancer Institute
Legacy Good Samaritan campus
15700 SW Greystone Court
Medical Office Building 3, Suite 150
Beaverton, OR 97006
1130 NW 22nd Ave.
Phone number: 971-262-9000
Portland, OR 97210
Fax number: 503-346-8058
Phone number: 971-262-9600
Fax number: 503-346-8058
Tualatin
Gresham
Legacy Meridian Park campus
Legacy Mount Hood campus
Medical Office Building 2, Suite 140
Medical Office Building 3, Suite 140
19260 SW 65th Ave.
24988 SE Stark
Tualatin, OR 97062
Gresham, OR 97030
Phone number: 971-262-9700
Phone number: 971-262-9500
Fax number: 503-346-8058
Fax number: 503-346-8058
Provider signature:
Date/Time:
Printed Name: _________________________ Phone: ______________ Fax: _____________
Infusion orders located at:
PO
-8064
ONLINE 06/2015 [supersedes 07/2014]
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