|
Patient's Supply? If yes, slide admin fee
|
Administration fee - Insurance
|
|
Administered by
• • •
|
|
|
Toradol
|
Dosage
|
|
Site
|
Lot and Expiration
|
|
Adacel
|
Dosage
|
|
Site
|
Lot and Expiration
|
|
Flu
|
Manufacturer
|
|
Site
|
Lot and expiration
|
|
Flu High Dose
|
Manufacturer
|
|
Site
|
Lot and expiration
|
|
Testosterone
|
Volume (cc/mL)
|
|
Site
|
Lot and Expiration
|
|
TB Test
|
Administered by
• • •
|
|
Site
|
Result
• • •
|
|
Rocephin
|
Dosage
|
|
Site
|
Lot and expiration
|
|
Vitamin B12
|
Dosage
|
|
Site
|
Lot and Expiration
|
