POLAR™ Healthcare | Vascular Access Referral Form
Part 1 of 3 REQUIRED FORM.
FAX SECURE: (281)-606-0455
Please FAX Patient's History & Physical with Recent Labs (CBC / PTT / INR) and Provider's Order for Vascular Access
Patient Full Name
Indicate patient's full name
Date of Birth
Indicate patient's date of birth
Gender
Male
Female
Other
Patient Phone Number
Indicate patient's phone number
Format: (000) 000-0000.
Patient Email Address
example@example.com
Patient Home Address
Please indicate patient's Home Address
MRN If Applicable
Referring Provider
*
Please Indicate Provider (MD, PA, NP)
Signature
Provider NPI:
Please Indicate Provider NPI Number
Today's Date
-
Month
-
Day
Year
Indicate Date of Provider Signature
Clinic / Facility
Indicate name of clinic or facility initiating referral
Facility Phone
Indicate reliable call back number of clinic or facility initiating referral
Format: (000) 000-0000.
Facility FAX
Indicate clinic or facility FAX number
Format: (000) 000-0000.
Vascular Access Services Order
PICC Line (PowerPICC+ 3CG Confirmation TCS)
MIDLINE Catheter(PowerGlide / Extended Dwell)
Ultrasound Guided Placement
Single Lumen - PICC
Double Lumen - PICC
Triple Lumen - PICC
Secure with Sutures
Secure with Sutureless Device Only
Type in other orders not listed above
Please indicate any additional orders
Urgency of Order
Activate POLAR™ STAT (<4 Hours Placement)
Routine Placement (Non-emergent)
Clinical Indications
IV Antibiotics
TPN / Nutrition Support
Chemotherapy / Infusion
Other
If 'Other' for Clinical Indication
Please indicate purpose for Vascular Access Service
Insurance Provider
Please indicate patient insurance provider
Policy Number
Please indicate policy number
Group Number
Please indicate policy number
POLAR™ Healthcare |
Vascular Access Referral
Form
info@polarhealthcare.net www.polarhealthcare.net
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POLAR™ Healthcare | Flushing Protocol Form
Part 2 of 3 REQUIRED FORM.
Patient Full Name
Indicate patient's full name
Date of Birth
Indicate patient's date of birth
Gender
Male
Female
Other
Patient's Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Patient's Email Address
example@example.com
Patient's Home Address
Please indicate patient's Home Address
MRN if Applicable
Referring Provider
*
Please indicate Provider (MD, PA, NP)
Signature
Provider NPI:
Please indicate Provider NPI Number
Today's Date
-
Month
-
Day
Year
Indicate Date of Provider Signature
Clinic / Facility
Indicate name of clinic or facility initiating referral
Facility Phone
Indicate reliable call back number of clinic or facility initiating the referral
Format: (000) 000-0000.
Facility FAX
Indicate clinic or facility FAX number
Format: (000) 000-0000.
Indicate the Vascular Access Type for Flushing Protocol
PICC Line
MIDLINE Catheter
Regular PIV (Ultrasound Guided)
Implanted Port
Tunneled Central Line (CVC)
Non-Tunneled Central Line (CVC)
Hemodialysis Catheter
Other
Authorized Flushing Solution
Normal Saline 0.9%
Heparin Lock Flush (If applicable)
Indicate Volume for Normal Saline 0.9% Flush
5 mL
10 mL
Other
Indicate Volume for Heparin Lock Flush (if applicable)
5 mL
10 mL
Other
Frequency of Flushing
Weekly maintenance
Before and after medication administration
Daily (when not in use)
Per institutional / infusion pharmacy protocol
After blood draws
Other
Blood Return Verification
Confirm blood return prior from use
If no blood return perform the following:
Reposition / Flush Per Protocol
Hold use and notify provider
Follow de-clot protocol if ordered
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POLAR™ Healthcare | Dressing & Catheter Care Order Form
Part 3 of 3 REQUIRED FORM.
Patient Full Name
Indicate patient's full name
Date of Birth
Indicate patient's date of birth
Gender
Male
Female
Other
Patient's Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Patient's Email Address
example@example.com
Patient's Home Address
Please indicate patient's Home Address
MRN if Applicable
Referring Provider
*
Please indicate Provider (MD, PA, NP)
Signature
Provider NPI
Please indicate Provider NPI Number
Today's Date
-
Month
-
Day
Year
Indicate Date of Provider Signature
Clinic / Facility
Indicate name of clinic or facility initiating referral
Facility Phone
Indicate reliable call back number of clinic or facility initiating the referral
Format: (000) 000-0000.
Facility FAX
Indicate clinic or facility FAX number
Format: (000) 000-0000.
Indicate the Vascular Access Type for Dressing & Catheter Care
PICC Line
Midline Catheter
Regular PIV (Ultrasound Guided)
Implanted Port
Tunneled Central Line (CVC)
Non-Tunneled Central Line (CVC)
Hemodialysis Catheter
Other
Indicate dressing type
Transparent semipermeable dressing
Gauze dressing
CHG-impregnated dressing (Biopatch / Tegaderm CHG)
Other
Indicate frequency of dressing change
Every 7 days (Transparent)
PRN if loose, damp, soiled, or compromised
Every 48 hours (Gauze) if bleeding
Other
Securement Method
Sutureless stabilization device (StatLock / equivalent)
Sutures (if applicable)
Cap / Connector Care
Needless connector change
Disinfect hub before access
Scrub the hub minimum of 30 seconds
Assessment & Escalation
Assess site for redness, drainage, swelling, pain, migration
If signs of infection: hold line use, notify provider, and document & report per POLAR protocol.
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