TUBERCULOSIS PRESCRIPTION / MEDICATION REQUEST FORM 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the 'Date Needed at Facility' to ensure timely processing of the request.
3. Fill in the patient's details, including 'Last Name', 'First Name', 'DOB', and 'Weight'. If applicable, check the boxes for gender and pregnancy status.
4. Specify the 'Projected Start Date' for medication and indicate any known allergies or current medications being taken.
5. Select whether this is a new medication request or a modification of an existing order. Indicate how doses will be dispensed (bottles or unit dose packs).
6. Complete the drug order section by filling in the required fields for each medication, including dosage, route, frequency, and total doses requested.
7. Add any special requests or notations as needed. Ensure that all provider information is accurately filled out, including signature and contact details.

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