Policy Manual sample

MDT Home Health Care Agency, Inc. ORDER FOR DRUGS Name of patient: Age of patient: __________________ Sex of patient: __________________ Drug(s) ordered: Quantity & Frequency: Date ordered: ___________________ Physician's name: Physician's address: Physician's phone number: ___________________ Comments: ________________________________________________________________ ________________________________________________________________ ____________________________________ Physician's signature: ____________________________________ Signature of staff responsible for patient Home Health Agency - - Skilled Professional Services D-45