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RemicadeĀ® (Infliximab) OrderForm

PATIENT INFORMATION

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History of CHF:

Allergies:

DIAGNOSIS

Allergies:

MEDICATION ORDERS

PREMEDICATION ORDERS:

FLUSH ORDERS:

REMICADE/INFLIXIMAB ORDERS:

Titration Schedule

10 ml/hr x 15 mins

20 ml/hr x 15 mins

40 ml/hr x 15 mins

80 ml/hr x 15 mins

150 ml/hr x 30 mins

250 ml/hr x 30 mins

NURSING/HOME HEALTH ORDERS

LAB ORDERS

PHYSICIAN INFORMATION

HIPPA

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