Individual Replenishment Form - Full Medication Pack

Medication Replenishment Form
Authorised Clinicians Only
Your Name
First NameLast Name
Email
example@example.com
Phone Number
Area CodePhone Number
Delivery Method
Postal Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code

Medicines Requested
Unscheduled Medications
Rows Quantity Requested (per sheet of 10) ADMIN ONLY: Qty Supplied ADMIN ONLY: Signature
Glucose Gel
Hartmanns Solution
Glucose 10% Solution

S2 Medications

Rows	Quantity Requested (per sheet of 10)	ADMIN ONLY: Qty Supplied	ADMIN ONLY: Signature
Aspirin 300mg tablets (sheets of 10)
Fexofenadine 180mg tablets (sheets of 10)
Ibuprofen 200mcg tablets (sheets of 10)
Paracetamol 500mg tablets (sheets of 10)

S3 Medications

Rows	Quantity Requested	ADMIN ONLY: Qty Supplied	ADMIN ONLY: Signature
Adrenaline 1mg/mL ampoule (1:1000)
Adrenaline Epipen 300mcg
Adrenaline Epipen 150mcg
Glucagon 1mg (1IU) powder for injection
Glyceryl trinitrate 0.3mg tablets (bottle of 100)
Salbutamol 100mcg MDI

S4 Medications

Rows	Quantity Requested	ADMIN ONLY: Qty Supplied	ADMIN ONLY: Signature
Adrenaline 1mg/10mL ampoule (1:100)
Amiodarone 150mg/3mL ampoule
Atropine 600mcg/mL ampoule
Benzyl Penicillin 600mg powder vial
Droperidol 10mg/2mL vial
Frusemide 40mg/4mL ampoule
Hydrocortisone 100mg vial
Ipratropium bromide 250mcg/mL vial
Ipratropium bromide 500mcg/mL vial
Lignocaine 1% 20mg/2mL ampoule
Lignocaine 2% 100mg/5mL ampoule
Methoxyflurane 3mL
Metoclopramide 10mg/2mL ampoule
Naloxone 400mcg/mL ampoule
Ondansetron 4mg/2mL ampoule
Salbutamol 2.5mg/2.5mL nebules
Salbutamol 5mg/2.5mL nebules

S4D Medications
Rows Quantity Requested ADMIN ONLY: Qty Supplied ADMIN ONLY: Signature
Midazolam 5mg/mL ampoule
S8 Medications
Rows Quantity Requested ADMIN ONLY: Qty Supplied ADMIN ONLY: Signature
Fentanyl 100mcg/2mL ampoule
Ketamine 200mg/2mL ampoule
Morphine 10mg/mL ampoule

Clinicians Declaration
I, {yourName}, confirm that I am requesting a Medication pack/replenishment of medications in accordance with my approved scope of practice .
I confirm that I will be responsible for my medication pack contents, and that when the medications are not in immediate use they must be stored in my possession apart from all other goods (other than cash or documents) in a separate room, safe, cupboard or other receptacle securely attached to a part of the premises, and kept securely locked when not in immediate use.
I confirm that upon approval and receipt of the medications, that I will immediately record the incoming order into my medication record book.
I confirm that upon receipt of medications, I will complete the "receipt of medications" form that is found in the delivery box to confirm I have received the medications. I will post this back to Resqmed Services Head Office within 48 hours of receipt. **Please note it is NSW Health legislation that no scanned or photographed copies of the confirmation of receipt of medications are allowed - only handwritten receipts of medication are accepted by NSW Health**
I confirm that there have been no changes or updates to my AHPRA registration status or conditions (if AHPRA registered), and I declare that there are no new criminal convictions not previously disclosed.
Signature
Date
DayMonthYear
Date
Should be Empty:

Medication Replenishment Form