Name:
Gender:
D.O.B.
/
dd
CCAC Community Infusion
Parenteral Medication Prescription
/
mm
yyyy
HCN:
Address:
Phone Number:
(Mobile preferred)
Line Type: □ Peripheral
□ PICC - # lumens: __________ □ Port
□ Other: _____________________
Reason for IV: _________________________________________________________________________________
Allergies: □ NKDA or Please List: __________________________________________________________________
IV Therapy Selection (A separate form needs to be completed for each IV medication)
□ Ampicillin
□ Gentamicin**
Dose:
□ Cefazolin
□ Imipenem/Cilastatin
□ CefTAZidime
□ Meropenem
Frequency:
□ Ceftriaxone
□ Metronidazole
□ q24h
□ q8h
□ q4h
□ Ciprofloxacin
□ Penicillin G
□ q12h
□ q6h
□ Other:
□ Clindamycin
□ Pipercaillin/Tazobactam
□ Cloxacillin
□ Tobramycin
Duration of remaining treatment:
□ Colistimethate
□ Vancomycin*,**
# of Days or
# of Doses
□ Ertapenem
□ Other:
□ Last dose in Hospital
or □ CCAC to Start IV
* If treatment is required for greater than 7 days, Community
Date: _________________ Time: _________
Vancomycin Therapy requires a Central Line.
**
If Drug Levels are required, ordering physician directs
patient to lab as CCAC does not provide lab services.
Hydration Orders
□ Normal Saline – 0.9 % Sodium Chloride □
Route:
□ IV
□ Subcutaneous
Volume/Dose
ml
*
Time: _________
Other Hydration solutions:
Duration of Community Treatment:
Rate*
Frequency:
First Dose due in Community:
Date: _________________
ml/hr
# of Days or
# of Doses
Special Instructions:
Max IV rate for adults is 250 mL/hr.
Other Hydrations available include:
Potassium Chloride 20 meq.l in Normal Saline, Lactated Ringers, Dextrose 5% and 0.45% Sodium Chloride, Dextrose 5% and 0.9% Sodium
Chloride and Dextrose 3.3% and 0.3% Sodium Chloride.
Flushing Protocol
□ Standard Flush Protocol:
Partners Resources
□ Alternate Flush Protocol: (Specify)
To consult a community Pharmacist with medication questions call
Yurek Specialties Limited Phone: 519-680-2416 ext. 405 or 1-888-637-3690
Physician / Nurse Practitioner (Please Print Clearly):
Name:
CPSO#
Signature:
Telephone:
Facility:
Cell/Pager:
Date:
Revised May 2016
Fax:
Please Complete and Fax this order form to: SWCCAC 519-472-4045 or 1-855-223-2847
Please provide patient or their family member with the Important Patient Handout (page 2)
Partners making a Referral to the CCAC
Page 1 of 2
Name:
Gender:
D.O.B.
/
dd
CCAC Community Infusion
Parenteral Medication Prescription
/
mm
yyyy
HCN:
Address:
Phone Number:
(Mobile preferred)
Important Patient Information
About IV Therapy
Intravenous (IV) Therapy has been ordered by your Doctor or Nurse
Practitioner to support your health.
You can expect this therapy to be set up for you by a Care Coordinator from
the Community Care Access Centre (CCAC).
1) A CCAC Care Coordinator will call you to:
 Assess your needs
 Arrange nursing services
2) The CCAC Pharmacy will call you to set up delivery of your IV medication(s)
and supplies. Someone must be home to accept the delivery.
3) The Nursing Provider will call you to set up the appointment and will
confirm your location.
Note: If your Doctor / Nurse Practitioner requests bloodwork, they have to
give you a lab requisition. You will need to contact your local lab to get the
bloodwork done. CCAC does not provide this service.
If you have not heard from the CCAC, the Pharmacy, or the Nursing Provider
please call the CCAC.
CCAC Phone Number
1-800-811-5146 or 519-473-2222
Hours of Operation
8:00 am – 8:00 pm, 7 days per week
Revised May 2016
Partners making a Referral to the CCAC
Page 2 of 2