<html> <head> <meta charset="UTF-8"/> <meta name="tikaGenerated" content="true"/> <meta name="date" content="2019-10-04T05:17:20Z"/> <meta name="xmp:CreatorTool" content="Adobe InDesign 14.0 (Macintosh)"/> <meta name="trapped" content="False"/> <meta name="meta:creation-date" content="2019-10-01T02:39:41Z"/> <meta name="created" content="Tue Oct 01 12:09:41 ACST 2019"/> <meta name="xmpTPg:NPages" content="1"/> <meta name="Creation-Date" content="2019-10-01T02:39:41Z"/> <meta name="dcterms:created" content="2019-10-01T02:39:41Z"/> <meta name="Last-Modified" content="2019-10-04T05:17:20Z"/> <meta name="dcterms:modified" content="2019-10-04T05:17:20Z"/> <meta name="Last-Save-Date" content="2019-10-04T05:17:20Z"/> <meta name="meta:save-date" content="2019-10-04T05:17:20Z"/> <meta name="producer" content="Adobe PDF Library 15.0"/> <meta name="modified" content="2019-10-04T05:17:20Z"/> <meta name="Content-Type" content="application/pdf"/> </head> <body> <pre> 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: </pre> </body> </html>