CRASH Rx
Quick Look & Submission
Bag Number
*
Is Bag Sealed
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Serial Number of Seal
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Pharmacy Seal
Pharmacist - Prepared By
*
First Name
Last Name
Expires
*
-
Day
-
Month
Year
Expiry Date Of Bag
Prescribing Clinician
*
First Name
Last Name
Email
*
example@example.com
Department
Please Select
ED
ITU
Etomodate 20mg/10ml (Qty: 1)
Please Select
2
1
0
Induction
Rocuronium 50ml/5ml (Qty: 2)
Please Select
2
1
0
Muscle Relaxant
Epinephrine 1:10 000 10ml (Qty: 1)
Please Select
1
0
Vasopressor
Saline Flush 10ml (Qty: 1)
Please Select
1
0
Flush
Additional Comments
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