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Axis House - Admission Checklist/Referral with
Inclusion/Exclusion Criteria: Updated Aug 2018
Mental Health & Substance Use Axis House
Castlegar location Phone: 778 460 1901
Fax: 778 460 1902
Axis House – Admission Checklist/Referral
Referral Source: ______________________________ PHN:
_____________________________
Patient Name: ______________________________ DOB:
_____________________________
Patient phone number: ______________________________ Allergies:
____________________________
** Please fill out Plan G and send copy with information** Plan
G initiated 1. Safety:
Inclusion / Exclusion criteria on back side reviewed.
Urine Drug Screen complete (all referrals)
2. Substance Withdrawal Plan (see attached pre-printed orders):
ALCOHOL
Bloodwork completed (see orders)
OPIATES
STIMULANTS
3. Assessment of Previous Withdrawal (indicate only if
applicable): History of Seizures History of Delirium tremens
4. Medical Assessment Completed: Medically stable
Current medical conditions if any:
________________________________________________________________________________________________________
5. Psychiatric Assessment Completed: Psychiatrically stable.
Current psychiatric diagnosis if any:
_____________________________________
6. Current Medications: Prescription required for all
medications during stay, please prescribe these on Physician’s
orders
7. Housing: Withdrawal Management Program Staff with work with
the Individual to link to resources in the community to support
finding suitable housing if needed. If homeless the client is aware
he/she may be discharged back to a homeless state.
8. Handout for clients: “What to Bring” and “Occupancy
Guidelines” given to client for review.
Fax copies of prescription and protocols to Axis House – 778 460
1902 Date: ________________________ PHYSICIAN’S NAME:
__________________________ PHYSICIAN’S SIGNATURE:
________________________________ As referring Physician, I am
prepared to follow the patient while in the program. Contact
number: __________________________ Axis on-call Physician to follow
the patient while in the program.
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Axis House - Admission Checklist/Referral with
Inclusion/Exclusion Criteria: Updated Aug 2018
.
Axis House Inclusion / Exclusion Criteria INCLUSION:
Client doesn’t need to be hospitalized.
o No significant health risks, such as any history of previous
uncontrolled seizures, no complicated withdrawal predicted.
o No physical or psychiatric symptoms (client is currently
stabilized).
Client is independent with daily activities, able to mobilize,
and willing to cooperate with treatment.
Client has been assessed by physician and medications ordered as
needed. EXCLUSION:
Complicated withdrawal is predicted.
Has experienced difficult withdrawal requiring hospitalization
in past.
Recent head injury or loss of consciousness (unrelated to
effects of intoxication).
Serious medical conditions/acute psychosis.
Unable to climb minimum of 3 stairs, high fall risk, poor
mobility.
Unable to do ADLs including feeding, toileting and showering
self.
Current severe nutritional disorder that requires medical care
(e.g. IV care).
Clients who are certified under the Mental Health Act.
Recent violent or physically aggressive behavior.
GENERAL INFO:
. Physician support is required. If admitting physician is
unable to provide ongoing support, please designate Axis
on-call
physician to assume care. Admissions and discharges are at the
discretion of the Axis House RN.
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June 2018
WITHDRAWAL Protocol for Adults
SYMPTOM MANAGEMENT and OPIATE AGONIST THERAPY Orders
MEDICATIONS: Multivitamin ONE dose PO / daily
Folic Acid 5mg PO daily
DimenhyDRINATE 25 to 50 mg PO /IM / Q4-6H PRN nausea
Acetaminophen 325-650mg PO Q4-6H PRN pain/headache (max. of
4g/24 hrs)
Ibuprofen 200-400mg PO QID PRN for pain/headache
Ranitidine 150mg BID PRN for heartburn
Calcium Carbonate 500-1000mg PO chewable Q4H PRN heartburn
Sennoside 8.6mg Tabs -2 Tabs BID PRN for constipation
Loperamide 2-4 mg PO PRN for diarrhea
Calcium 333mg/Magnesium 1-2 tabs po prn for mild muscle cramping
(max. of 3 tabs/24hr)
OPIATE AGONIST THERAPY (for Buprenorphine/Naloxone Induction,
please complete page 2)
BC Centre on Substance Use/Ministry of Health Guideline for the
clinical management of Opioid use disorders states: Withdrawal
Management
alone is not an effective treatment for opioid use disorder, and
offering this as a standalone option to patients is neither
sufficient nor appropriate.
Please check to order: □ Clonidine 0.1mg PO TID PRN for symptoms
of withdrawal (hold if diastolic BP
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June 2018
WITHDRAWAL Protocol for Adults
SUBOXONE (Buprenorphine/Naloxone) Induction Orders
NURSING CONSIDERATIONS:
DELAY INDUCTION UNTIL CLIENT HAS ABSTAINED FROM OPIATE USE FOR A
MINIMUM OF 12-24 HOURS In the interim, use Clonidine (see below) as
indicated
Monitor withdrawal symptoms using the Clinical Opiate Withdrawal
Scale (COWS) Assess client using COWS prior to each and every dose,
and 1 hour after administration of each and every dose Each
administration must be witnessed directly by staff Client must be
advised to refrain from eating, drinking, speaking, smoking for
10mins while sublingual tablets dissolve Staff to remain in
client’s presence for 10mins after administration of each dose
Day 1
Administer initial dose of 4mg/1mg Buprenorphrine/Naloxone
SL
If withdrawal symptoms are not adequately relieved after 1-3
hours: administer additional 2mg/0.5mg Buprenorphrine/Naloxone SL,
reassess in another 1 hour
Repeat hourly until withdrawal symptoms are adequately relieved
or to a max of 12mg/3mg on Day 1.
Day 2
Ascertain whether Day 1 dose was sufficient to adequately
relieve withdrawal symptoms o If withdrawal symptoms were
adequately relieved on Day 1: administer the total dose received on
Day 1 (dose will be
between 4mg/1mg - 12mg/3mg Burprenorphrine/Naloxone SL) o If
withdrawal symptoms were NOT adequately relieved on Day 1:
administer 16mg/4mg Buprenorphine/Naloxone SL
Day 3
Ascertain whether Day 2 dose was sufficient to adequately
relieve withdrawal symptoms o If withdrawal symptoms were
adequately relieved on Day 2: administer that dose again (dose will
be between 4mg/1mg
- 16mg/4mg Burprenorphrine/Naloxone SL) o If withdrawal symptoms
were NOT adequately relieved on Day 2: administer 20mg/5mg
Buprenorphine/Naloxone SL
Day 4
Ascertain whether Day 3 dose was sufficient to adequately
relieve withdrawal symptoms o If withdrawal symptoms were
adequately relieved on Day 2: administer that dose again (dose will
be between 4mg/1mg
- 20mg/5mg Burprenorphrine/Naloxone SL) o If withdrawal symptoms
were NOT adequately relieved on Day 3: administer 24mg/6mg
Buprenorphine/Naloxone SL
Maintenance dose is achieved when client is no longer
experiencing uncomfortable symptoms of Opiate withdrawal. It may be
reached on any of the induction days thus induction may take LESS
than four days. This maintenance dose will be the client’s daily
dose moving forward unless otherwise indicated.
□ Clonidine Option (please check to order):
Clonidine 0.1mg PO TID PRN for symptoms of withdrawal PRIOR to
Day 1 induction OR for precipitated withdrawal symptoms only
(withhold dose if diastolic BP less than 60 mm Hg)
o Avoid use for 8hrs prior to first Buprenorphine/Naloxone dose
as it may mask withdrawal symptoms and interfere with
successful titration
Prescribers must agree to (or assign a designate) to continue
outpatient Opiate Agonist Therapy at conclusion of inpatient
therapy. TRIPLICATE PRESCRIPTION MUST ACCOMPANY THIS ORDER to Axis
House by FAX, and mail original to Simply Shoppers Pharmacy, #117
1983 Columbia Ave., Castlegar BC, V1N 2W8 Physician/NP signature:
Date/Time:
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Safety Bulletin: Avoid the use of withdrawal management as a
standalone treatment for opioid use disorder Recommendation:
Withdrawal management alone is not an effective treatment for
opioid use disorder, and offering this as a standalone option to
patients is neither sufficient nor appropriate. Care providers
should clearly communicate to patients the risks of withdrawal
management as a standalone strategy and encourage a period of
opioid agonist therapy or a slower outpatient taper (e.g., > 3
months) with methadone or buprenorphine/naloxone. In the event that
patients choose to proceed with withdrawal management without
follow-up treatment, providers may consider using an informed
consent form or waiver to document that this decision has been made
against medical advice. A sample waiver is appended to this
document. Risks of Detox: Acute withdrawal management (also known
as “detox”) is an intervention aimed at reducing health harms, such
as withdrawal seizures, associated with substance use cessation.
However, as a standalone intervention, withdrawal management does
not constitute “addiction treatment,” and can be associated with
harm, especially in the context of opioid use disorder. What the
Research Says: Research has shown that, when offered as an isolated
intervention for opioid use disorder, inpatient withdrawal
management may leave patients particularly vulnerable to the
following serious health harms:
Nearly universal rates of relapse to opioid use – Abrupt (e.g.,
< 1 week) taper off of opioids results in the vast majority of
individuals returning to opioid use.1
Elevated risk of overdose – Individuals who relapse following
withdrawal management are at increased risk of overdose as a result
of the rapid loss of tolerance to opioids.2
Elevated risk of infection – Studies have shown that, in
comparison to offering nothing, persons who inject drugs who
undergo withdrawal management are more likely to contract HIV and
Hepatitis C, likely as a result of high risk behaviours upon
relapse.3,4
Opioid Agonist Therapy: In British Columbia, inpatient opioid
withdrawal programs are generally rapid (e.g., 1 week). When risk
of relapse presents upon discharge, continuity of care can be
particularly challenging as waitlists and other programmatic
barriers often prevent immediate readmission to inpatient
withdrawal or other safe environments. Instead of rapid inpatient
opioid tapers, studies suggest that opioid agonist therapy (OAT)
using buprenorphine/naloxone or methadone is more effective in
terms of patient retention and satisfaction, sustained abstinence
from opioid use, and decreased risk of morbidity and mortality
related to overdose, HIV and HCV transmission.3-6 Outpatient
Withdrawal Management: For patients who wish to discontinue opioid
use without long-term OAT, a slow (e.g., > 3 month) outpatient
taper with buprenorphine/naloxone or methadone should be an
available option to address continuity of care issues associated
with discharge from inpatient care, and ensure ongoing close follow
up with an outpatient care provider should longer term OAT be
necessary. Slower (e.g., up to one year) tapers have been
associated with improved rates of abstinence and successful
discontinuation of OAT.7 Additionally, referral to an
evidence-based residential treatment or an intensive outpatient
addiction program should be considered for all individuals with
opioid use disorder who decline long-term OAT.
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Specific Populations: Although inpatient, rather than
outpatient, withdrawal management has traditionally been
recommended for specific patient populations, such as individuals
with concurrent mental health conditions, these patients may be
particularly vulnerable to harm from short term (e.g. one week)
inpatient opioid withdrawal management. For these patients, as with
patients without serious comorbidities, outpatient community care
involving OAT or slow tapers off of opioids through community-based
withdrawal management involving ongoing addiction treatment should
be prioritized. Using Inpatient Withdrawal Management Effectively:
Inpatient withdrawal management can be an important first point of
contact and act as a bridge to ongoing addiction treatment.
Additionally, inpatient facilities can provide more intensive
monitoring, support and symptom management, and may be appropriate
care settings for challenging OAT inductions or transitions between
treatments (e.g., methadone to buprenorphine/naloxone). For
additional support, physicians should consider contacting the Rapid
Access to Consultative Expertise (RACE) telemedicine addiction
support at 604-696-2131 (raceconnect.ca). For further reading,
please refer to the BCCSU/Ministry of Health Guideline for the
Clinical Management of Opioid Use Disorder at
http://www.bccsu.ca/wp-content/uploads/2017/02/BC-OUD-Guidelines_FINAL.pdf.
References
1. Wright NM, Sheard L, Adams CE, et al. Comparison of methadone
and buprenorphine for opiate detoxification (LEEDS trial): a
randomised controlled trial. The British journal of general
practice : the journal of the Royal College of General
Practitioners. 2011;61(593):e772-780.
2. Strang J, McCambridge J, Best D, et al. Loss of tolerance and
overdose mortality after inpatient opiate detoxification: follow up
study. BMJ. 2003;326(7396):959-960.
3. MacArthur GJ, Minozzi S, Martin N, et al. Opiate substitution
treatment and HIV transmission in people who inject drugs:
systematic review and meta-analysis. BMJ. 2012;345:e5945.
4. MacArthur GJ, van Velzen E, Palmateer N, et al. Interventions
to prevent HIV and Hepatitis C in people who inject drugs: A review
of reviews to assess evidence of effectiveness. International
Journal of Drug Policy. 2014;25(1):34-52.
5. Mattick RP, Breen C, Kimber J, Davoli M. Buprenorphine
maintenance versus placebo or methadone maintenance for opioid
dependence. Cochrane Database Syst Rev. 2014;2:CD002207.
6. Esmaeili HR, Ziaddinni H, Nikravesh MR, Baneshi MR, Nakhaee
N. Outcome evaluation of the opioid agonist maintenance treatment
in Iran. Drug Alcohol Rev. 2014;33(2):186-193.
7. Nosyk B, Sun H, Evans E, et al. Defining dosing pattern
characteristics of successful tapers following methadone
maintenance treatment: results from a population-based
retrospective cohort study. Addiction (Abingdon, England).
2012;107(9):1621-1629.
http://www.bccsu.ca/wp-content/uploads/2017/02/BC-OUD-Guidelines_FINAL.pdf
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CONSENT AND RELEASE FORM FOR WITHDRAWAL MANAGEMENT SERVICES
Patient Label: By checking the boxes below and signing this consent
form, I confirm that I understand and/or agree with the following
statements: I understand that I have been diagnosed with an Opioid
Use Disorder.
I understand that, according to current medical evidence, the
safest and greatest chance of
recovery from opioid use disorder can be achieved by starting
opioid agonist treatment with buprenorphine/naloxone or methadone
(first-line agents). The recommended duration of opioid agonist
treatment varies depending on individual needs and
circumstances.
I understand that if I choose to proceed with withdrawal
management (also known as ‘detox’)
without follow-up care, I have a high risk of relapse, and a
high risk of overdose due to decreased tolerance to opioids.
Overdose can cause severe harms including brain damage, coma, and
death.
I understand that withdrawal management alone is against medical
advice. I have been given sufficient time and opportunity to ask
questions about the information above,
and have received satisfactory clarification and advice. I fully
release and discharge the physician and staff from any
responsibility or liability for any losses,
damages, or injuries I may suffer as a result of my decision not
to go on opioid agonist treatment. I consent to undergo withdrawal
management services to be provided by the physician and care
team, and have opted not to pursue follow-up care at this
time.
Client Signature Date
Physician, Nurse or Staff Name and Signature Date
affix here
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Mental Health Substance Use Centres or Child and Youth Mental
Health Service Centres: Fax this form to Health Insurance BC at 250
405-3896.
Select the most applicable options.
I certify that: a. The patient has been hospitalized for a
psychiatric condition.
b. Without prescribed medication, the patient is likely to be
hospitalized for a psychiatric condition.
c. Without prescribed medication, the patient or another person
is likely to suffer serious physical or psychological harm, or
economic loss.
PSYCHIATRIC MEDICATION COVERAGEAPPLICATION FOR PHARMACARE PLAN
G
A. TO BE SIGNED BY THE APPLICANT (PLEASE SEE INSTRUCTIONS ON
REVERSE)
HLTH 3497 Rev. 2016/12/21 PAGE 1
NOTE: FORMS SUBMITTED BY UNAUTHORIZED PERSONS OR WITH INCOMPLETE
MANDATORY FIELDS WILL BE RETURNED. If applicant contact information
is not provided, the applicant cannot be notified of coverage
expiration.For more information on Plan G or to access this form
online, visit www.gov.bc.ca/pharmacareprescribers.
If you have received this fax in error, please write
“MISDIRECTED” across the front of the form and fax it back to the
sender.
Name - mandatory Phone Number
Address Postal Code
Personal Health Number (PHN) - mandatory Birthdate (YYYY / MM /
DD)
Personal information on this form is collected under the
authority of section 22 of the Pharmaceutical Services Act for the
operations of PharmaCare’s Psychiatric Medications Drug Plan (Plan
G). The personal information will be used to support the applicant
to be a Plan G beneficiary. Personal information will be released
to PharmaCare and to a Mental Health Substance Use Centre for the
provision of drug benefits. If you have any questions about the
collection of personal information on this form, contact your local
health authority or Health Insurance BC (HIBC)–from the Lower
Mainland: 604 683-7151 or, from elsewhere in B.C., toll free at 1
800 663-7100. This information will be used and disclosed in
accordance with the Freedom of Information and Protection of
Privacy Act and the Pharmaceutical Services Act.
Applicant Signature - mandatory Date Signed
B. PRACTITIONER ONLY – TO BE SIGNED BY THE PRESCRIBING
PRACTITIONER (PHYSICIAN OR NURSE PRACTITIONER)
Name of Prescribing Physician or Nurse Practitioner
Physician/Nurse Practitioner: Fax this form to your local Mental
Health Substance Use Centre, Child and Youth Mental Health Service
Centre, OR the mental health contact at your local health authority
to complete Section C for approval. Do NOT fax directly to Health
Insurance BC.
Phone Number Fax Number
Signature of Prescribing Physician or Nurse Practitioner -
mandatory
C. MENTAL HEALTH SUBSTANCE USE CENTRE / HEALTH AUTHORITY ONLY –
APPROVAL
1 year Less than 1 year
Authorization Expiration
Centre Name - mandatory
Name of Director or Designate
Date Signed
D. HEALTH INSURANCE BC PROCESSING
I declare that the cost of prescribed psychiatric medication is
a significant barrier to my taking my medication. I have no other
financial coverage, and I believe I qualify for Medical Services
Plan Premium Assistance ($42,000 family adjusted net income plus
$3,000 per dependent).
Practitioner College ID Number - mandatory
Site Location ID
Signature of Director or Designate - mandatory
Phone Number Fax Number
Date SignedExpiry Date (YYYY / MM / DD)This authorization will
expire in:
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PSYCHIATRIC MEDICATION COVERAGEAPPLICATION FOR PHARMACARE PLAN
G
HLTH 3497 PAGE 2
Instructions for Authorized Persons completing this form:
If the applicant is unable to sign the form:1. Ensure all
required fields are complete.
2. Have the applicant verbally declare that they meet the Plan G
eligibility requirements but are unable to sign the Plan G
application.
3. Write “Verbal Declaration” in the Applicant Signature box of
the Plan G application.
4. Sign your name as a witness in the Applicant Signature box
beside the words “Verbal Declaration.”
If the applicant is unwilling to sign the form:1. Ensure all
required fields are complete.
2. Have a person who is legally empowered* to sign the
application on behalf of the applicant sign their name in the
Applicant Signature box of the Plan G application.
3. Indicate in writing, beside their signature, the legal
authority that empowers them to make the declaration on the
applicant’s behalf.
OR
*A person legally empowered to sign must be one of the
following: a committee appointed under the Patients Property Act, a
person acting under a power of attorney, a litigation guardian, or
a representative acting under a representation agreement.
PLAN G
Plan G coverage is provided for a set period not exceeding one
year. When this period expires, the practitioner may re-apply for
continued coverage.
Plan G coverage may be extended to new residents who have not
yet qualified for the B.C. Medical Services Plan (MSP). In this
case, the practitioner must submit a written request with the
application for Plan G coverage, detailing the patient’s compelling
need for exceptional coverage. If approved, Plan G coverage will be
provided for a period of three months, during which time the
patient must apply for MSP.
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Please give to client to review before admission.
WHAT TO BRING
o Health Care Card and Extended Health ID
o Comfortable clothing sufficient for 4 days
o Appropriate sleepwear including socks or slippers for your
feet
o Long distance phone card if you want to call long distance
o Toiletries: toothbrush, toothpaste, hair products, deodorant,
hair dryer, shaving supplies, lotion, (NO
PRODUCTS CONTAINING ALCOHOL OR AEROSOLS WILL BE ALLOWED)
o If you smoke please bring enough cigarettes (in unopened
packages) for 5 days. We do not allow opened
packages of cigarettes brought in, chewing tobacco, hand rolled
cigarettes, flavoured cigarettes, cigars.
Nicorette gum or nicotine patches are acceptable but must be
brought into the program new/ unopened.
E-juice brought into the program must be sealed and
unopened.
WHAT NOT TO BRING
The following list contains items that clients are not permitted
to have in their possession. If these items are
brought into the program, they will be kept locked up until you
complete the program.
o No outside food or drinks, including water, candy, or chewing
gum.
o No cell phones, computers, tablets, music equipment,
televisions, i-pods, mp3 players, clock radios,
cameras
o No expensive jewellery or excessive cash.
o No hair dye, bleaching products, nail polish and remover
o No perfume, cologne, aftershave, strong perfumed lotions and
bath products.
o No alcohol or drugs
o No pictures or photos that depict alcohol/ drug usage,
violence or sex
o No weapons of any kind, including scissors
o No clothing that depicts alcohol, drugs, sex, or violence.
o No straight razors and/ or razor blades
o No pillows, blankets, sheets, towels, or stuffed toys
o No zippos, lighter fluid or butane,
o No E-juice that is alcohol or cannabis flavoured.
o No short shorts, halter tops, shirts that show your
midriff
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Page 1 of 1
Please give to client to review before admission.
OCCUPANCY GUIDELINES
1. Visitors are not allowed at the withdrawal management
program.
2. All alcohol, drugs, and paraphernalia found in the possession
of a client will be confiscated and destroyed. Use of
alcohol or other drugs at the program may result in termination
of services.
3. Staff reserves the right to conduct room searches at any time
there may be a concern for the safety of clients and staff.
4. All products containing alcohol (e.g., mouthwash, hair spray,
cologne, after shave, etc.) will be confiscated at time of
admission and returned at time of discharge.
5. All items considered to be a threat to client safety (e.g.,
razors, knives, and scissor’s) will be confiscated at time of
admission and returned at time of discharge. Clients may use
safety razors and other hygiene-related “sharps” only with
permission.
6. Cell phones, computers, tablets, CD’s, DVD, I-pods, MP3
players and other devices are not allowed to remain in a
client’s possession while at the withdrawal management program.
These items will be stored with other client valuables
and returned at time of discharge.
7. Smoking: Cigarettes, E- Vapes, cigars, lighters, matches,
etc. will be confiscated at time of admission and stored in the
staff office. Smoking is restricted to designated outdoor areas.
Clients will be allowed to go outside to smoke every
two hours when staff is available to supervise. Smoking indoors
is strictly prohibited and may result in termination of
services. Clients taking medications that are incompatible with
nicotine will not be allowed to smoke while in the
withdrawal program. All tobacco products and lighters will be
returned to clients at time of discharge.
8. Clients must inform unit staff of special dietary needs or
food allergies so that arrangements can be made with the food
service contractor.
9. Clothing items that advertise or glorify alcohol, drugs, sex,
or violence cannot be worn.
10. Television will be turned off at 11 p.m.
11. Client phone calls are permitted during scheduled quiet
times throughout the day. Times include: 1:15 pm - 2:45 pm, and
6:30 pm -7:00 pm (time limit of 10 minutes per person for
calls).
12. Any physical contact between clients, including consensual
sex, is prohibited.
13. Physical fighting, threats, harassment, damage to or theft
of property are prohibited and may result in legal charges and
removal from the program.
I, ____________________________ have read the client guidelines
outlined in the Admission Handbook and agree to
remain in compliance with these terms. If I experience
difficulty with any aspect of it, I will approach staff for
guidance.
_____________________________ __________________________
_____________________
Client Name Written: Client Signature: Date Signed:
_____________________________ __________________________
_____________________
Axis Staff Written: Axis Staff Signature: Date Signed:
AdmRef Checklist June 2018Opiate OrdersBCCSU Safety Bulletin and
ContractCastlegar Plan G FormCastlegar - What to BringCastlegar
Occupancy Guidelines (1)
Name: Phone Number: Address: Postal Code: PHN: Birthdate: Date
Signed1: Patient has been hospitalized: OffWithout medication
likely hospitalization: OffPatient suffer harm: OffName of
Prescribing Physician: Practitioner ID: Date Signed2: Practitioner
Phone: Practitioner Fax: Centre Name: Site Location ID: Name of
Director or Designate: Designate Phone: Designate Fax: Date
Signed3: Authorization Expiration: OffExpiry Date: Print: Clear
Form: