address); $p_address_text=""; foreach ($p_arddress as $pa) { //echo $pa; if(isset($pa)&& $pa!=""){ $p_address_text=$p_address_text.$pa.', ';} } //echo $p_address_text; //print_r($p_arddress); ?>

order_status!=""){ $documents_status=$md_order->order_status; }else{ $documents_status='Processing'; } ?>

ICD-10

Medication

level_of_service=='4' || $patient->level_of_service=='5'){ ?>

Lab Order

Lab Drawn

LabDrawn=="Yes"){ echo "Checked"; }?>> Yes

LabDrawn=="No"){ echo "Checked"; }?>> No

InfactingOrganismType=="NA"){ echo "Checked"; }?>> N/A

InfactingOrganismType=="CultureNotDone"){ echo "Checked"; }?>> Culture Not Done

InfactingOrganismType=="CulturePending"){ echo "Checked"; }?>> Culture Pending

Flush Volume (ml's)	0.9 % Saline	Heparine 10 units/ml	Heparine 100 units/ml
Before Dose :
Between Doses :
After Dose :
Other :
QSOD through :

Administration supplies as required

AdministrationSupplies=="YES"){ echo "Checked"; }?>> YES

AdministrationSupplies=="NO"){ echo "Checked"; }?>> NO

level_of_service=='4' || $patient->level_of_service=='5'){ ?>

staticdynamicFormData==""){ ?>

Nursing Procedure: STOP any Infusion or medication administration immediately

1. If Modarate to severe symptoms occur, activate EMS system and initiate BCLS if indicated.

2. If applicable have caregiver call 911.

3. Notify the physician at phone.

4. Administer Medications below as needed for Acute Infusion Reaction to .

ANAPHYLAXIS TREATMENT
Check	Drug of Treatment	Severity	Under 15kg	15 - 30Kg	Over 30Kg	Quantity	Route	Note



	Other Medications or O2
		Medicate to Severe

5. If reaction subsides, resume infusion at one half previous rate and increase gradully to a rate no greater than previous rate

6. If reaction does not subside

a. Continus to follow BCLS.

b. Contract Prescriber for additional medical management .

c. Remain with patient until EMS arrives.

Refill

Additional Order Information

For medicare patient in the Home Setting only. Administration supplies as required

YES

staticdynamicFormData; ?>

Acceptence=="accepted"){ echo "Checked"; }?>>

I, the ordering prescriber for the medication, have no financial relationship with the WeCuro Inc that would prohibit the provision of the therapy. I hereby certify that the above infusion and services are medically necessary and are authorised by me. The Patient is under my care and is in the need of the services listed.

Signature phy_signature!=""){ ?>

Approved By : submitted_by; ?> On : submitted_on; ?>

Entered By : submitted_by; ?> On : submitted_on; ?>

Order Date

Signature submit_signature!=""){ ?>

Entered By : submitted_by; ?> On : submitted_on; ?> phy_signature!=""){ ?>

Approved By : submitted_by; ?> On : submitted_on; ?>

Order Date

phy_signature)){ ?>

PATIENT DEMOGRAPHICS

Order Details

ICD-10

Medication

Lab Order

Nursing Procedure: STOP any Infusion or medication administration immediately