Pertussis Pathway - Children's Hospital Central California
Pertussis Pathway - Children's Hospital Central California
Pertussis Pathway - Children's Hospital Central California
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1234567Name: ____________________________________ Relationship: ________________ DOB: _______ Wt: _____ kg.Allergies: _________________________________ Other Med/Medical conditions: _____________________________________________________________________________________________________________________________Funding source: __________________ Rx Given/Type: ___________________________ Filled: yes noPMD:______________________________________________________________Name: ____________________________________ Relationship: ________________ DOB: _______ Wt: _____ kg.Allergies: _________________________________ Other Med/Medical conditions: _____________________________________________________________________________________________________________________________Funding source: __________________ Rx Given/Type: ___________________________ Filled: yes noPMD:______________________________________________________________Name: ____________________________________ Relationship: ________________ DOB: _______ Wt: _____ kg.Allergies: _________________________________ Other Med/Medical conditions: _____________________________________________________________________________________________________________________________Funding source: __________________ Rx Given/Type: ___________________________ Filled: yes noPMD:______________________________________________________________Name: ____________________________________ Relationship: ________________ DOB: _______ Wt: _____ kg.Allergies: _________________________________ Other Med/Medical conditions: _____________________________________________________________________________________________________________________________Funding source: __________________ Rx Given/Type: ___________________________ Filled: yes noPMD:______________________________________________________________Name: ____________________________________ Relationship: ________________ DOB: _______ Wt: _____ kg.Allergies: _________________________________ Other Med/Medical conditions: _____________________________________________________________________________________________________________________________Funding source: __________________ Rx Given/Type: ___________________________ Filled: yes noPMD:______________________________________________________________Name: ____________________________________ Relationship: ________________ DOB: _______ Wt: _____ kg.Allergies: _________________________________ Other Med/Medical conditions: _____________________________________________________________________________________________________________________________Funding source: __________________ Rx Given/Type: ___________________________ Filled: yes noPMD:______________________________________________________________Name: ____________________________________ Relationship: ________________ DOB: _______ Wt: _____ kg.Allergies: _________________________________ Other Med/Medical conditions: _____________________________________________________________________________________________________________________________Funding source: __________________ Rx Given/Type: ___________________________ Filled: yes noPMD:______________________________________________________________Patient Label0540*0540*<strong>Pertussis</strong> <strong>Pathway</strong> 12/2002Exposure Contact List
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