FORM 03 2010 Initial Immunosuppression and Antibiotics (PG 1 of 1)-2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the Institutional Code and Sequential Patient Number at the top of the form. Ensure you use black ink for clarity.
3. In Section A, indicate whether Induction Therapy was used. If 'Yes', provide specifics such as agent names, start and stop dates for each induction agent.
4. Continue through each subsection, filling in details for Azathioprine, Cyclosporine, Mycophenolate, Sirolimus, Tacrolimus, and Steroids. For each medication, specify if it was administered post-op and include daily doses.
5. In Section B, list any prophylactic antibiotics or antivirals started pre-op through 30 days post-op. Mark all applicable options and provide discharge date.
6. Finally, sign your name in the designated area and note the date when the original form is mailed.

Start using our platform today to fill out your forms easily and efficiently!