Phoenix Patient OCS Medication
*
Administered Medication
Spilled Medication
In Office Medication
Patient Name:
First Name
Last Name
Weight:
Pounds
Birth Day:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Medication:
Midazolam
Hydroxyine
Medicated Midazolam In Milliliters:
Milliliters
Medicated Hydroxyzine Capsules:
Capsules
Disp/Wasted Midazolam in Milliliters:
Milliliters
Disp/Wasted Hydroxyzine Capsules:
Capsules
Select medication in office:
Midazolam Checked In
Hydroxyzine Checked In
In Office Medication Amount:
Milliliters or Capsules
*
Please Select
Dr.Heil
Yari
Leslie
Jordan
Nidia
Madalyn
Dr.Garrett
Dr.Kyle
Bell Assistant
PCH Assistant
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Should be Empty: