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Refill x INDIVIDUAL ORDERS Epinephrine 1 10 000 0. 01mg/kg IM for anaphylaxis as directed Arrange home health care agency to administer . Current Kg Parent/Guardian Name Address Phone Insurance Provider s Name Provider s Address Provider s Phone NICU Graduate Yes No Unknown Provider s Fax Date of first dose Location of first dose Received last year yes Gestational Age 28 wks 6 days 29 wks 0 days to 31 wks 6 days 32 wks 0 days to 34 wks 6 days ICD Code 765. Attached is the form Prior...
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