IV Therapy

IV Therapy/OPAT Team

Form

Patient details

If contact details are incorrectly input where mandatory the referral cannot be processed
Patient has consented to information sharing?*
Overseas visitor?
Any social issues e.g. carers?*
If drug is not listed below then the patient cannot be referred into the service. Please contact IV Team direct on 07908 529 195 to discuss alternate treatment options
Please note that the patient cannot be referred for four times per day treatment

Referrer details

If contact details are incorrectly input where mandatory the referral cannot be processed

Communication

Can the patient communicate easily?*

Environment

Can the patient open their door?*

Request details - bloods

Does the patient require a blood test?
If yes, which blood test(s)?
Please send blood forms home with patient.

Request details - wound care

Does the patient require wound care?
Any sutures to be removed?
Are the required dressing with the patient?
Has the prescription been sent and will the item be at the patient house?