Policy Manual sample

MDT Home Health Care Agency, Inc. 50 MDT Home Health Care Agency, Inc. FIRST DOSE REGISTRATION FORM Name: __________________________________________________________________ Address: ________________________________________________________________ Doctor: ______________________________________MD Phone #:________________ Prescribed medication: _____________________________________________________ 1. Do you have allergies to any medications or IVP dye? YES NO 2. Do you have any other allergies (i.e., foods)? YES NO 3. Have you ever received this medication in IV, IM, SQ or YES NO intraspinal form previously? If yes, did you have any problems? Please explain:______________________________________________ _________________________________________________________ I understand that I am receiving the first dose of an intravenous (IV), intramuscular (IM), Subcutaneous (SQ) or intraspinal medication in the home. I will be monitored by an RN who is familiar with the treatment for an allergic reaction. Emergency medications have been ordered by my physician and are available in the home. I am aware that if a medical emergency does occur, EMS will be contacted at the following phone number: ______________________. Signature of patient/legal representative: ___________________________________________ Date: ___________________ Signature of RN: ____________________________________________ Date: ___________________