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PROVIDER NAME
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Is the PT 18 years of age or older?
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Is Patients parent or legal guardian present
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Does patient have any Medical Conditions?
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If YES, please list:
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Does patient take any medications?
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If YES, please list:
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Does patient have any allergies?
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If YES, please list:
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Is patient pregnant or breastfeeding?
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History of B12 or Folic Acid deficiencies
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Current diagnosis of anemia
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Additional Comments
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Standing Orders:
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Discussion with Patient
• • •
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Signature of Patient
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I approve this patient for the requested procedure(s) as noted in this document
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Name/Signature of NP/PA/MD
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