CDF00034 Guest Dosing Request

Guest Dosing Request

To be filled out by Home Clinic
CompDrug 547 E 11th Avenue Columbus, OH 43211 Phone: 614.224.4506 Fax: 614.291.0118
Medication Hours Mon, Thurs, & Fri: 6am - 1pm Tues & Wed: 530am - 1pm Saturday: 6am - 9am Sunday: Closed
Patient Information
Patient Name *

First Name Last Name
Date of Birth *

Month Day Year
Date
SSN *
Race *
Gender *
Clinic Information
Name of Home Clinic *
Address of Home Clinic *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Clinic Phone Number *
Please enter a valid phone number.
Clinic Fax Number *
Please enter a valid phone number.
Clinic Email
example@example.com
Medication Information
Type of Medication *
Medication Dose *
mgs Per Day
Date to Start Medication *

Month Day Year
Date
Date to End Medication

Month Day Year
Date
Dose Confirmed By: *
Must be Physician, RN, or LPN
Is Patient Transferring? *
Click Here for Transfer Criteria
Per CompDrug's Medical Director, patients can guest dose for a maximum of 14 days. Picture ID is required Cost: $20 per day ( correct change, money order, or credit card ) Payment is required on day of service This form must be completed & returned prior to medication Please notify CompDrug if guest dosing services are canceled A Release of Information MUST accompany this request A lock box is required on Saturday for Sunday & Holiday take-home medication Lock box must be ALL metal with key or combination lock No take-home medication is given for guest dosing with the exception of Sundays and holidays We will not guest dose above 200mgs of Methadone a day
Signature of person completing this form *

Clear
Prohibition on Re-Disclosure 42 CFR part 2 prohibits unauthorized disclosure of these records
Should be Empty:

Guest Dosing Request

Patient Information

Clinic Information

Medication Information