Rx & Tactical Rx
Quick Look and Submission
Type
*
Please Select
Rx SCRAM
Tactical RX
Version Of Rx
Bag Number
*
Is bag sealed?
*
Serial Number of Seal
*
Pharmacy Seal
Bag Expires
*
-
Day
-
Month
Year
Expiry Date Of Bag
Pharmacist - Prepared By
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date
Prescribing Clinician
*
First Name
Last Name
Email
*
example@example.com
Team
*
Please Select
EMRS West
EMRS North
Tayside Trauma Team
Medic 1
Fentanil 100mg/2ml (Qty: 2)
*
Please Select
2
1
0
Opioid
Ketamine 200mg/20ml (Qty: 2)
*
Please Select
2
1
0
Induction
Rocuronium 50ml/5ml (Qty: 4)
Please Select
4
3
2
1
0
Muscle Relaxant
Saline Flush 10ml (Qty: 4)
Please Select
4
3
2
1
0
Flush
Midazolam 5mg/5ml (Qty: 2)
*
Please Select
2
1
0
Benzodiazepine
Epinephrine 1:10 000 10ml (Qty: 1)
Please Select
1
0
Vasopressor
Miscellaneous
Morphine 10mg/ml (Qty: 2)
*
Please Select
2
1
0
Tranexamic Acid 500mg/ml (Qty: 2)
Please Select
2
1
0
Calcium Chloride 10% (Qty: 1)
Please Select
1
0
Ceftriaxone 2g (Qty: 1)
Please Select
1
0
Propofol 2% 20ml (Qty: 1)
Please Select
1
0
Water for injection 10ml (Qty: 2)
Please Select
2
1
0
Additional Comments
Submit
Should be Empty: