Diabetic Supplies MD-DIAB-001

Pharmacist-initiated ordering of diabetic monitoring supplies under medical directive

Practice Information

Pharmacy *

Implementing Pharmacist *

Patient Information

Patient Name *

Date of Birth *

Phone

Date of Service

Eligibility & Consent

Diabetes Type / Indication *

Intervention Type *

Duration (months, max 12) *

Patient consent obtained — informed of medical directive authorization

⚠ Exclusion Criteria — check any that apply (blocks use of directive)

Patient requires emergency care for DKA / HHS Patient has refused care / consent

Supply Items

Clinical Framework

Clinical Rationale

Patient Education Provided

Authorizing Prescriber (from Medical Directive)

Prescriber Name *

Designation

Registration # *

Clinic / FHT

Prescriber Phone

Prescriber Fax

PMS Note Preview