Restricted Antibiotic Request Form
Submit a request for approval to prescribe restricted antibiotics. Please complete all required fields to ensure timely review.
Requesting Physician Full Name
*
First Name
Last Name
Physician Email Address
*
example@example.com
Department/Unit
*
Please Select
Internal Medicine
Infectious Diseases
Surgery
Intensive Care Unit
Pediatrics
Other
Patient Name
*
First Name
Last Name
Patient Hospital Number (if available)
Clinical Diagnosis / Indication for Antibiotic Request
*
Previous Antibiotics Used (within this admission)
*
Requested Restricted Antibiotic
*
Please Select
Carbapenem
Linezolid
Daptomycin
Colistin
Tigecycline
Other
Planned Dose and Duration
*
Justification for Restricted Antibiotic Use (brief rationale)
*
Relevant Laboratory Results (e.g., culture, sensitivity)
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of
Urgency of Request
*
Routine
Urgent
Physician Signature
*
Submit Request
Submit Request
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