Get the free Naloxone Intake Form (Version 3.5) - Data Dictionary/Guide - odh ohio
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NALOXONE INTAKE FORM
TRANSFER TO AGENCY
FOR OFFICE USE ONLY
Setting:
Form identification number: ___
Community Access Point
Court System
ED/Urgent Care
FHC/only Clinic
Hospital System
Jail/Corrections
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How to fill out naloxone intake form version
How to fill out naloxone intake form version
01
Obtain a naloxone intake form version from a healthcare provider or pharmacy.
02
Read and follow the instructions on the form carefully.
03
Fill in your personal information, including name, date of birth, and contact details.
04
Provide information about your medical history and any medications you may be taking.
05
Indicate any allergies or sensitivities you have to medications.
06
Sign and date the form to confirm that the information provided is accurate.
07
Return the completed form to the healthcare provider or pharmacy where you obtained it.
Who needs naloxone intake form version?
01
Individuals who have been prescribed naloxone for the treatment of opioid overdose.
02
Individuals who have a history of opioid use or are at risk of opioid overdose.
03
Caregivers or family members of individuals at risk of opioid overdose.
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What is naloxone intake form version?
The current version of naloxone intake form is Version 2.0.
Who is required to file naloxone intake form version?
Healthcare providers and pharmacies are required to file naloxone intake form version.
How to fill out naloxone intake form version?
To fill out naloxone intake form version, healthcare providers need to enter patient information, details of naloxone prescription, and monitoring information.
What is the purpose of naloxone intake form version?
The purpose of naloxone intake form version is to track the distribution and use of naloxone to help combat opioid overdoses.
What information must be reported on naloxone intake form version?
Information such as patient demographics, prescriber details, pharmacy information, and naloxone administration details must be reported on naloxone intake form version.
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