RESTRICTED ANTI-MICROBIAL ORDER FORM

DATE:

Hospital No. Ward:

Patient Name: Gender:
Allergy: Age:
Body Weight (kg) Transaminases:

Serum Creatinine: Creatinine

Clearance:
Antimicrobial
Requested
Dosing Regimen
Indication for use (include reason for
not using recommended
antimicrobial)

Date Specimen Pathogen Identified

Microbiological Results

Outcome of Verbal Approval:

Requesting Physician’s Requesting Physician’s
Name & Signature Contact Number:

PREUTHORIZATION FOR RESTRICTED ANTIMICROBIALS ONLY

Approved Not Approved
No. of Days approved for use: __________days Reason:
Remarks:
Approver

Name/Signature: DATE:

DOH Antimicrobial Stewardship Program FOR STRICT COMPLIANCE