AUTHORITY FOR ADMINISTRATION OF MEDICATION BY A WAIPUNA HOSPICE PALLIATIVE CARE NURSE Please send BOTH the completed authority form AND prescription to: Unichem Metro Pharmacy, Bethlehem Fax: 07 579 3483 or email: Bethlehem.metro@unichem.co.nz Waipuna Hospice - fax: 07 552 4386 Prescriber Name: _____________________ Please affix Patient Label Here
Registration Number: _________________
PATIENT ALLERGIES: SYRINGE DRIVER AUTHORITY – Infuse the following medications subcutaneously over 24 hours Date
Medication
Dose
Signature
Stopped/changed date & signature
For patients on a fentanyl patch, please document fentanyl patch dose_________mcg/hr
AUTHORITY FOR MEDICATIONS IN SYRINGE DRIVER TO BE INCREASED OR DECREASED IF INDICATED Date
Medication
Increase/decrease amount:
Daily maximum 24 hour dose
Signature
Indication/ special instructions
Signature
AS NEEDED ‘PRN’ MEDICATIONS AUTHORITY Date
Medication
Dose/ range
Route Subcut Subcut Subcut
Page 1 of 2
Frequency
Page 2 of 2