FOR APPOINTMENTS CALL 07 5647 6001

         
Robina HQ Building: 
Suite 21 (Level 2) 58 Riverwalk Avenue
(Corner of 1 Laver Drive) 
Robina 4226
Phone: 07 5647 6001  Fax: 07 5647 6016
E: Infusions@flowhealth.com.au 
Medical Objects: Dr Sarah Hunt 446159GX
       
Date of Referral: <TodaysDate>
		
Patient Details:	Referring Doctor:	
Name:  <PtFullName>    (D.O.B.: <PtDoB>)	<DrName>	
Medicare:  <PtMCNo> - <PtMCLine>  Exp  <PtMCExpiry>	Provider No. <DrProviderNo>	
Phone: <PtPhoneMob>  or   <PtPhoneH>	<UsrAddress>	
Address: <PtStreet> <PtCity> <PtState> <PtPostcode> 	Phone: <UsrPhone>	

Medication Order

Medication: Zoledronoic Acid
Dose: 5mg in 100mL
Standard Duration: 15 mins OR Extended Duration <Extended Infusion Duration (mins)> mins
(Additional fee applies to extended duration times)
Route: Intravenous infusion
Frequency: Once Only
Special Instructions: <Special Instructions:>

Clinical Details

Creatinine Cl >35: <Creat Cl >35>
Vitamin D Level: <Vit D level > 50>
Last Infusion Date: <Last infusion Date (if known)>  OR First Infusion <First Infusion?>
Dental Health UTD: <Dental Health UTD?>
Known Allergies: <Reactions>

Prescribing Doctor Confirmation
I request the Flow Health Nurse to administer the medication as ordered to this Patient. I confirm that the prescribed treatment is not contradicted for this Patient. 

SIGNATURE:  ________________________________	<TodaysDate>	
Medication will be prepared and administered as recommended in the current relevant Zoledonic Acid Australian Product Information (PI) available at: www.ebs.tga.gov.au

In the case that a patient displays an acute reaction in the presence of a Flow Health Nurse, during or after the infusion, the nurse will administer emergency treatment in accordance with the Flow Health anaphylaxis protocol. 

 Facsimile 07 5647 6016 | Email infusions@flowhealth.com.au | Web www.flowhealth.com.au