N. Gonorrhea Treatment Order Form

*Medications are to be used for N. Gonorrhea Treatment ONLY

Health Care Professional (HCP) Information
Health Care Professional's Name * Required
First Last
Health Centre/Family Health Team * Required
Address * Required
Street Address Address Line 2 City Province Postal Code
Email * Required
Phone * Required
Gonorrhea First Line Treatment - Number of Treatment Kits Required * Required
(Treatment Kits include; Ceftriaxone 0.25g vial, Lidocaine HCI 1% 0.9mL, Azithromycin 250mg tab x4)
Notes
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Health Unit Use Only
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Ceftiaxone 0.25g vial - Lot Number
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Lidocaine HCI 1% 0.9mL - Lot Number
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Azithromycin 250mg tab x4 - Lot Number
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Order filled by
First Name Last Name
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Delivery/Pick-up Date
YYYY slash MM slash DD
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Health Unit Notes
-
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Health Care Professional (HCP) Information