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Activate Treatment Plan:
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IV Bag:
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Select Size of Initial NS Bag:
• • •
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Amino Blend* - 3 mL
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Banana Bag (Infuvite*) - 10 mL
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Banana Bag (Vial 1 ONLY*) - 5 mL
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Banana Bag (Vial 2 ONLY*) - 5 mL
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BCAA* (Female) - 2 mL
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BCAA* (Male) - 3 mL
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Biotin (0.5 mg/mL) - 1 mL
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Caffeine Citrate (20 mg/mL) - 3 mL
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L-Arginine (200 mg/mL) - 1 mL
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Magnesium Sulfate (500 mg/mL) - 2 mL
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mAb Bamlanivimab (700 mg/20 mL) - 20 mL
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Lilly Batch Number:
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mAb Etesevimab (700 mg/20 mL) - 40 mL
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Lilly Batch Number:
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mAb Casirivimab (300 mg/2.5 mL) - 5 mL
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REGEN-COV Batch Number:
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mAb Imdevimab (300 mg/2.5 mL) - 5 mL
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REGEN-COV Batch Number:
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mAb Sotrovimab (500 mg/8 mL) - 8 mL
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GSK Batch Number:
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NAD + (250 mg)
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NAD + (500 mg)
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NAD + (750 mg)
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NAD + (1,000 mg)
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Taurine (50 mg/mL) - 1 mL
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Vitamin B-2 (Riboflavin) (50 mg/mL) - 0.5 mL
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Vitamin B-3 (Niacin) (100 mg/mL) - 1 mL
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Vitamin B-5 (Dexpanthenol) (250 mg/mL) - 1 mL
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Vitamin B-6 (Pyridoxide) (100 mg/mL) - 1 mL
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Vitamin B-12 (Hydroxocobalamin) (1 mg/mL) - 1 mL
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Vitamin B-12 (Hydroxocobalamin) (2 mg/mL) - 0.50 mL
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Vitamin B12 (Methylcobalamin) (5mg/mL)- 1mL
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Vitamin B-Complex* - 1 mL
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Vitamin C (Ascorbic Acid) (500 mg/mL) - 3 mL
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Zinc Chloride (0.50 mg/mL) - 3 mL
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Zinc Sulfate (10 mg/mL) - 0.15 mL
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Zinc Sulfate (10 mg/mL) - 0.25 mL
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Zinc Sulfate (10 mg/mL) - 0.40 mL
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Tri-Immune Boost (Glutathione 200mg/mL, Ascorbic Acid 200mg/mL, and Zinc Sulfate 2.5mg/mL
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1. Additional Nutrient via IV Bag:
• • •
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1. # mL
• • •
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2. Additional Nutrient via IV Bag
• • •
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2. # mL
• • •
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3. Additional Nutrient via IV Bag:
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3. # mL
• • •
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Additional Saline:
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Select Size of 2nd Bag of NS:
• • •
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Select Size of 3rd Bag of NS:
• • •
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IV Push:
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Select Site of IV Push:
• • •
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Benadryl (Diphenhydramine) (50 mg/mL) - 0.5 mL
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Compazine (Prochlorperazine) (5 mg/mL) - 2 mL
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Glutathione (200 mg/mL) - 3 mL
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mAb Bebtelovimab (175 mg/2 mL) - 2 mL
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Lilly Batch Number:
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Pepcid (Famotidine) (10 mg/mL) - 2 mL
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Reglan (Metoclopramide) (5 mg/mL) - 2 mL
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Toradol (Ketrorolac) (30 mg/mL) - 1 mL
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Zofran (Ondansetron) (2 mg/mL) - 2 mL
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1. Additional Nutrient via IV Push:
• • •
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1. # mL
• • •
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2. Additional Nutrient via IV Push:
• • •
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2. # mL
• • •
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3. Additional Nurtrient via IV Push:
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3. # mL
• • •
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Other Injections:
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Select either IM or SQ Injection:
• • •
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Select Site of Injection:
• • •
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Other Injection Site (if applicable):
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Semaglutide 0.25mg
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Semaglutide 0.5mg
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Semaglutide 1mg
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Semaglatide 1.5mg
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Semaglutide 2mg
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Semaglutide 2.5mg
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Lipo-C (MIC) - 1 mL
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Lipo Mino Mix - 1 mL
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MICC - 1 mL
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Toradol (Ketrorolac) (30 mg/mL) - 1 mL
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Vitamin B-12 (Hydroxocobalamin) (1 mg/mL) - 1 mL
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1. Other Nurtrient via IM or SQ Injection:
|
1. # mL
• • •
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2. Additional Nurtrient via IM or SQ Injection:
|
2. # mL
• • •
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Infusion Details:
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Select Site of IV:
• • •
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Other IV Site (if applicable):
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Enter Number of Attempts:
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Select Angiocath Size:
• • •
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Enter Starting HR:
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Enter Ending HR:
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Enter Starting BP:
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Enter Ending BP:
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Standard Infusion Note:
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Enter Complications:
• • •
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Enter Custom Note:
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