Drug Request
Please submit your order by 10 AM for next day pick-up
** Refrigerated drug ordered on a Friday will not be delivered to DCOP until the following Tuesday**
Nurse
*
Nurse Email
*
Protocol ID
*
Patient Study #
*
Patient Initials
Patient Weight
Date Required
-
Month
-
Day
Year
Date
Time Required
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
CTEP Site Code(Previous field/Hidden))
Dispense Drug to:
*
IN034 RH
OH060 SEYH
OH085 VA
OH086 KMC
OH119 WPMC
OH152 BVHS
OH156 GDCC
OH252 DP-E
OH260 OHC
OH291 SJWH
OH308 SEBH
OH415 WH
OH456 SOIN
OH466 DP-Troy
OH470 AFCC
OH471 DP-A
Physician
Nurse
Drug Information
Drug Name
Dose / Strength
# of Vials / Bottles
Drug 1
Drug 2
Drug 3
Drug 4
Would you like a Drug Accountability Record Form (DARF)?
Control Form
Satellite Form
None
Dispensing site (Previous/Hidden)
*
Dayton Physicians - 8881 N. Main St
Dayton Physicians - 3120 Governor's Place
Cancer Specialist of Greater Dayton
Kettering Cancer and Blood Specialists
WPMC
Other
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