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Infusion Order
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Reason for Infusion:
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IV Access
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IV Location
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IV Attempts
• • •
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Myer's Cocktail
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Other Modification:
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MIC
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Ascorbic Acid (Vitamin C)
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Other Modification:
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Cancer
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Zinc
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Other Modification:
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L-Lysine
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Other Modification:
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Vitamins
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Alphalipolic Acid
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Other Modification:
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BCAA
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Other Modification:
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B Complex or VitaComplex
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Other Modification:
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B-17 (Amigdalina)
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Other Modification:
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Biotin
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Other Modification:
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Calcium Chloride
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Other Modification:
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Calcium Gluconate 10%
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Other Modification:
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CALM
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Other Modification:
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Chromium
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Other Modification:
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Dexpanthenol
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Other Modification:
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Folic Acid
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Other Modification:
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Glutathione
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Other Modification:
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L -Argenine
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Other Modification:
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L-Carnitine
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Other Modification:
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L-Glutamine
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Other Modification:
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L-Glycine
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Other Modification:
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LIPO MINO
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Other Modification:
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LIPO Stat Plus
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Other Modification:
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Magnesium Chloride
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Other Modification:
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Methylcobalamin
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Other Modification:
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Methyltetrahydrofolic Acid
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Other Modification:
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MIC C
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Other Modification:
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Molybdenum
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Other Modification:
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MSM
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Other Modification:
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MultiTrace 5
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Other Modification:
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N-Acetyl L-Cystine
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Other Modification:
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NAD
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Other Modification:
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Procaine
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Other Modification:
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Pyridoxine
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Other Modification:
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Riboflavin
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Other Modification:
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Selenium
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Other Modification:
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Taurine
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Other Modification:
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Thiamine
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Other Modification:
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Tri-Amino
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Other Modification:
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Vitamin D
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Other Modification:
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Medications
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None
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Decadron
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Quantity
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Method
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Phenergan
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Quantity
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Method
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Nubain
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Quantity
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Method
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Norflex
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Quantity
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Method
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Toradol
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Quantity
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Method
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Rocephin
|
Quantity
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Method
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Valium
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Quantity
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Method
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Xanax
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Quantity
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Method
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Zofran
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Quantity
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Method
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Versed
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Quantity
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Method
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Narcan
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Quantity
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Method
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Regeneron Infusion
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Regeneron
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Dose
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Method
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Pt Education
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B/P prior to infusion
/
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B/P post infusion
/
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Pulse prior to infusion
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Pulse post infusion
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O2 Saturation prior to infusion
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O2 saturation post infusion
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Temperature Prior to infusion
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Temperature post infusion
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Comments
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Regeneron Lot #
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IV Fluids
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Fluid Volume
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Other
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Other:
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Signature
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Administering Staff Signature:
• • •
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Attending:
• • •
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