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MEDICATION AUTHORITY
Metropolitan Referral Unit Phone: 1300 110 600 Fax: 1300 546 104

SA Health

Created
June
2018

Affix patient identification label in this box

UR No: .............................................................................................

Surname: .........................................................................................

Given Name: ...................................................................................

Second Given Name: ....................................................................

D.O.B: .................................................... Sex: ............................

Allergies and Adverse Drug Reactions (ADR)

Medicine (or other)

Sign ....................................... Print .................................... Date ..............

Reaction / type / date Initials
? Nil Known ? Unknown (tick appropriate box or complete details below)

Page ......... of .........

Medicines required to be administered
(Prescriber must enter administration times)

Year 20 .........
Last Dose Given Prior to Transfer (Date/Time):

Record of drug administration

Date Medicine (print generic name)

Route

Indication

Commence Date Cease Date

Prescriber Signature Print your name

Dose Frequency

Dose Frequency

Dose Frequency

Dose Frequency

Contact

Tick if
Slow

Release

Last Dose Given Prior to Transfer (Date/Time):Date Medicine (print generic name)

Route

Indication

Commence Date Cease Date

Prescriber Signature Print your name Contact

Tick if
Slow

Release

Last Dose Given Prior to Transfer (Date/Time):Date Medicine (print generic name)

Route

Indication

Commence Date Cease Date

Prescriber Signature Print your name Contact

Tick if
Slow

Release

Last Dose Given Prior to Transfer (Date/Time):Date Medicine (print generic name)

Route

Indication

Commence Date Cease Date

Prescriber Signature Print your name Contact

Tick if
Slow

Release

Date

Admin
Time

Special instructions: .................................................................................................................................................................................................
.....................................................................................................................................................................................................................................

.....................................................................................................................................................................................................................................

.....................................................................................................................................................................................................................................

Doctors signature: ....................................................................................................................................................... Date: .................................
Print Name: ........................................................................................................................ Contact /pager Number: ..........................................

MEDICATION AUTHORITY
Metropolitan referral unit phone: 1300 110 600 Fax: 1300 546 104

Page  of 

Affix patient identification label in this box

UR No:  

Family Name: 

Given Name: 

Address: 

Date of Birth:  /  /   Sex: 


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