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attach patient label Physician Orders LEB Multivitamin Formulary Plan [X or R] = will be ordered unless marked out. PEDIATRIC Height: ___________cm Weight: __________kg [ ] No known allergies Allergies: [ ] Latex allergy [ ]Other:__________________________________________________________________ Medications [ ] multivitamin ( Poly-Vi-Sol Drops) 0.5 mL, Drops, PO, QDay, Routine [ ] multivitamin ( Poly-Vi-Sol Drops) 1 mL, Drops, PO, QDay, Routine [ ] multivitamin with iron ( Poly-Vi-Sol 0.5 mL, Liq, PO, QDay, Routine [ ] [ ] [ ] [ ] [ ] [ ] [ ] with Iron Drops) multivitamin with iron ( Poly-Vi-Sol with Iron Drops) multivitamin with minerals ( Flintstones Complete) multivitamin with iron ( Flintstones with Iron Chewable) multivitamin with minerals ( Unicomplex M ) multivitamin with minerals ( Cerovite Liquid ) multivitamin with minerals ( Cerovite Liquid ) multivitamin with minerals ( Cerovite Liquid ) 1 mL, Liq, PO, QDay, Routine 1 tab, Chew tab, PO, QDay, Routine 1 tab, Chew tab, PO, QDay, Routine, Multivitamin with iron not appropriate for correction of iron deficiency or for treatment of iron deficiency anemia. 1 tab, Tab, PO, QDay, Routine 5 mL, Oral Susp, PO, QDay, Routine 10 mL, Oral Susp, PO, QDay, Routine 15 mL, Oral Susp, PO, QDay, Routine Note: Cystic Fibrosis Vitamins [ ] [ ] [ ] [ ] [ [ [ [ ] ] ] ] multivitamin with minerals ( ADEKs oral tablet, chewable ) multivitamin with minerals ( ADEKs oral liquid ) multivitamin with minerals ( ADEKs oral liquid ) multivitamin with minerals ( AquADEKs ) Note: Nephrology Vitamins multivitamin multivitamin multivitamin multivitamin 1 tab, Chew tab, PO, QDay, Routine 1 mL, Drops, PO, QDay, Routine 2 mL, Drops, PO, QDay, Routine 1 cap, Cap, PO, QDay, Routine 1 tab, Tab, PO, QDay, Routine 0.5 mL, Liq, PO, QDay 1 mL, Liq, PO, QDay 5 mL, Liq, PO, QDay *065* LEB Multivitamin Formulary Plan-43006-PP-QM0609 111412 Page 1 of 2 attach patient label Physician Orders LEB Multivitamin Formulary Plan [X or R] = will be ordered unless marked out. PEDIATRIC Medications continued [ ] [ ] [ ] [ ] Note: Hypoallergenic Vitamins Nano VM Age 1-3 Nano VM Age 4-8 Nano VM T/F 9 to 18 years 1 packet, Packet, PO, QDay, Routine, DISSOLVE IN THICK LIQUIDS OR SOFT 1 packet, Packet, PO, QDay, Routine, DISSOLVE IN THICK LIQUIDS OR SOFT 41 mL, Oral Susp, PO, QDay, Routine, Comment: USE IMMEDIATELY AFTER PREPARING. MAY MIX WITH 30 ML OF WATER PER SERVING TO THIN PRIOR TO ADMINISTRATION Nano VM T/F 9 to 18 years 82 mL, Oral Susp, PO, QDay, Routine, Comment: USE IMMEDIATELY AFTER PREPARING. MAY MIX WITH 30 ML OF WATER PER SERVING TO THIN PRIOR TO ADMINISTRATION __________________ __________________ Date Time _________________________________________________ Physician's Signature LEB Multivitamin Formulary Plan-43006-PP-QM0609 111412 Page 2 of 2 __________________ MD Number
