Outpatient IVIG
Approval/Booking
Name:
DOB:
Page 1of 2
Request
PHN:
Pt. Phone #
Section A - Request: To be completed by ordering physician
Clinical Indication (required):
Primary Immune Deficiency Myasthenia Gravis (MG)
Secondary Immune Deficiency Dermatomyositis
Idiopathic Thrombocytopenic Purpura (ITP) Juvenile Dermatomyositis
Allogenic Stem Cell or Bone Marrow Transplant (BMT) Pemphis Vulgaris
Guillain-Barré syndrome (GBS) Other (indicate diagnosis)
Multifocal Motor Neuropathy
Chronic Inflammatory Demyelinating Polyradiculoneuropathy (CIDP)
Immune deficiency patients only: IgG trough level: g/L Date drawn:
ITP patients only: Platelet count: X10
9
/L Date drawn:
Wt: kg Ht: cm
Allergies: None known
Previous adverse reaction to IVIG? No
Yes, describe Antibiotic resistant organisms: None Unknown MRSA VRE ESBL
PICC/SVAD: No Yes, location
Medication
Medication
Medication
Relevant History:
Supplemental Infusion Orders:
Booking Information: Preferred hospital location for infusion(s):
Patient not available: Mon, Tue, Wed, Thu, Fri, Sat, Sun; Patient absences:
Consent for Transfusion of Blood Products:
Accompanies this form To be signed in outpatient nursing unit
* Physician must have reviewed benefits, risks and alternatives of receiving a blood product with patient.
Physician last and first name, middle initial:
Physician signature:
Date of request:
ORDERING PHYSICIAN: Fax completed form (page 1 and 2) to RJH Transfusion Medicine Lab (250-370-8190)
Print Form
Outpatient IVIG
Approval/Booking
Name:
DOB:
Page 2 of 2
Request
PHN:
Pt. Phone #
Section A Request (continued): To be completed by ordering physician
IVIG Dose Requested:
Frequency of infusion episodes: Every weeks
Induction /One time dose: g divided over day(s) ( g per day)
Maintenance dose:
g divided over
day(s) (
g per day)
Duration of series: 3 months 6 months 12 months Other, specify
Physician last and first name, middle initial:
Physician phone :
MSP Practitioner #:
Physician signature:
Physician fax:
Date of request:
Ordering physician:
Fax to 250-370-8190
Royal Jubilee Hospital
Transfusion Medicine Laboratory
Booking and clinical staff: Please check Approval section for any
modifications to this order prior to booking the patient or
administering the IVIG. Any modifications to the order from the
screening physician should be followed.
Section B - Approval: To be completed by Transfusion Medicine Lab screening physician
Adjusted body weight calculator used? No Yes, adjusted body weight: kg
Approved as requested
Not approved
Approved with the following modifications:
Frequency of infusion episodes: Every weeks
Induction /One time dose: g divided over day(s) ( g per day)
Maintenance dose: g divided over day(s) ( g per day)
Duration of series: 3 months 6 months 12 months Other, specify
Comments:
Ordering physician notified by phone. (Only required if dose modified or not approved.)
Date of screening:
Screening physician name (please print):
Screening physician signature:
To be completed by Royal Jubilee Hospital Transfusion Medicine Lab technologist
Faxed or copy sent to booking personnel Cerner updated Faxed to ordering physician
Tech initials:
Section C - Booking: To be completed by booking personnel at applicable site
Location of infusions:
Date/
Time
Date/
Time
Date/
Time
Date/
Time
Date/
Time
Date/
Time
Date/
Time
Date/
Time
Date/
Time
Date/
Time
Date/
Time
Date/
Time
ORDERING PHYSICIAN: Fax completed form (page 1 and 2) to RJH Transfusion Medicine Lab (250-370-8190)
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