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PROVIDER NAME
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Is the PT 18 years of age or older?
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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 Diabetes or Thyroid Cancer
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BMI 25-40
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History of liver or gallbladder disease
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New Short Text Field
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Additional Comments
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Standing Orders:
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Discussion with Patient
• • •
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MD/NP signature
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I approve this patient for the requested procedure(s) as noted in this document
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Medication
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Injection #/Treatment units/weight
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