Restricted Antimicrobial Order Form
Submit your restricted antimicrobial order request below. All fields are required for processing.
Requester Full Name
*
First Name
Last Name
Requester Email Address
*
example@example.com
Department or Unit
*
Please Select
Internal Medicine
Surgery
ICU
Emergency
Other
Patient Location (Room or Bed Number)
*
Restricted Antimicrobial Requested
*
Please Select
Vancomycin
Meropenem
Linezolid
Daptomycin
Other
Indication for Use
*
Please Select
Empiric Therapy
Definitive Therapy
Prophylaxis
Other
Urgency Level
*
Routine
Urgent
Stat
Preferred Administration Route
*
Intravenous
Oral
Other
Proposed Dose and Frequency
*
Proposed Duration (in days)
*
Submit Order
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