PCI Office Use Order Form

The receiving provider agrees to:

Only administer office use compounds to the patient. The compounds may not be sold or dispensed to any other person or entity except as authorized by §563.04 of the Act.
Document in the patient chart, separate log, or medication administration record the lot number and beyond-use-date of a compound which is administered to a patient.
Only order quantities that are reasonable and will be used prior to the beyond-use-date based on the history of the practice’s patient use.
Notify the pharmacy of any adverse reactions or complaints from patients.

Physicians' Choice Infusion Pharmacy Office Use Order Form