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PLACE LABEL HERE OUTPATIENT LABS and SUPPLEMENTION ORDERS Center For Surgical Weight Management The following orders will be implemented. Orders with a “” are choices and are NOT implemented unless checked. Initial all handwritten order modifications and the bottom of each page when indicated (multipage). 1. Diagnosis: Special Aftercare V58.4 following weightloss surgery 783.3 2. Labs: CBC, Ferritin, B-12, Calcium, Lipid Profile, CMP, Direct Bilirubin, Bone Alkaline Phosphatase (BAP), Total Vitamin D (25 OH), Hgb A1C (FAX results to 678-312-6241) 3. If levels are within normal range: No treatment indicated. 4. If levels are deficient nurse will call in prescription indicated below: IRON DEFICIENCY TREATMENT Hgb > 12 mg/ml and Ferritin > 20: No treatment Indicated Hgb 10-12 mg/ml and Ferritin < 20 (mild or moderate deficiency with or without Anemia): Multigen Plus Caplets, one po daily x 90 days (calcium, cyanocobalamin, ferrous fumarate, folic acid, succinic acid, iron) or If patient needs liquid, Nifrex Elixir 100 mg/ 5 ml, 7.5 ml po once daily x 90 days (ascorbic acid, biotin, copper, cyanocobalamin, docusate sodium, folic acid, iron, vitamin E) Hgb < 10 mg/ml and Ferritin < 20 (severe anemia) or refractory to oral treatment: refer to Hematologist VITAMIN D DEFICIENCY TREATMENT D 25 OH ( > 30 ng/ml): No treatment indicated D 25 OH (20-30 ng/ml): Cholecalciferol (D3) 10,000 international units po daily x 8 weeks D 25 OH (< 20 ng/ml): ______________ Date Ergocalciferol (D2) 50,000 international units po daily x 8 weeks ___________________ Time *1-32226* _________________________________ Physician Signature FORM 1-32226 REV. 08/2013 __________ PID Number Page 1 of 1