Fillable STI MEDICATION ORDER FORM (City of Toronto)

Fill Online, Printable, Fillable, Blank STI MEDICATION ORDER FORM (City of Toronto) Form

Use Fill to complete blank online CITY OF TORONTO pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

STI MEDICATION ORDER FORM (City of Toronto)

On average this form takes 15 minutes to complete

The STI MEDICATION ORDER FORM (City of Toronto) form is 1 page long and contains:

  • 2 signatures
  • 0 check-boxes
  • 53 other fields

Country of origin: CANADA
File type: PDF

Use our library of forms to quickly fill and sign your City of Toronto forms online.

BROWSE CITY OF TORONTO FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Health Care Provider / Clinic Contact Person (Print Name) Date of Request
Address
Postal Code
Telephone Number
Alternative Number for Courier
Fax Number
Monday Tuesday Wednesday Thursday Friday
Hours closed:
Special Instructions
iPHIS #
Authorizing PHN: PHN Signature: Date Approved:
Name of Recipient: Recipient Signature: Date Received:
Submit STI Drug Order
STI MEDICATION ORDER FORM
**IMPORTANT**
Due to COVID-19,
couri
ers no longer enter clinics or community settings.
Please provide 2 phone numbers for courier to call upon arrival for curbside pickup.
If the phone line is not answered, the order will be retur
ned to Tor
onto Public Health.
O
RDERING
HEALTH
CARE
PROVIDER
INFORMATION (Please complete all fields)
Hours of Operation
Closed for lunc
h:
Yes
No
(
Please
allow
5 business days for delivery of medication)
FIRST LINE TREATMENT FOR GONORRHEA: Ceftriaxone 250 mg IM plus Azithromycin 1 g PO, taken together
AVAILABLE STI MEDICATION FOR
ORDER
ROUTE UNIT SIZE UNITS REQUESTED
TPH OFFICE USE ONLY
L
OT
#
Expiry Date
Azithromycin 250 mg Oral
1.5 doses/box
Ceftriaxone 250 mg IM
10 doses/box
1% Lidocaine 5 mL – Diluent for Ceftriaxone
20 ampoules/box
Doxycycline 100 mg Oral
100 tabs/bottle
Penicillin G Benzathine (Bicillin) 1.2 MU
*(Need
to store in the fridge)
IM
10 syringes/box
Condoms
144 condoms/box
To
special
or
der
Gentamicin (for patients with cephalosporin allergy ONLY) or for questions regarding
alternative treatment regimens, please call intake at 416-338-2373
STI Medication Order Form is available on the web by searching medication order toronto.
Please send the completed order form as an email attachment by clicking the Submit STI Drug Order button (preferred option).
If an email doesn't appear automatically, save the completed form and send it as an email attachement to stiintake@toronto.ca, or
fax to the STI Program at (416) 338-0002. If you have any questions, please call the STI Program at (416) 338-2373.
416.338.7600 toronto.ca/health
Revision: 2020-10-16
To send via the Submit STI Drug Order button,
save the completed form to your computer first.
Submit STI Drug Order
click to sign
signature
click to edit
click to sign
signature
click to edit
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

STI MEDICATION ORDER FORM (City of Toronto)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 30 January 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document