TBS tarter Kit Form by 5SjJdD

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									SUPPLY TO: (indicate full address of Health Unit/Dept.)            MAIL COMPLETED FORM TO.

                                                                   Vaccine and Pharmacy Services
                                                                   BC Centre for Disease Control
                                                                   655 West 12th Avenue, Room 1100
                                                                   Vancouver, B.C. V5Z 4R4

Postal Code:                                                       Phone:        (604) 707-2580
                                                                   Fax:          (604) 707-2583
Telephone:

  TB STARTER                    DESCRIPTION                       DIRECTIONS AND             NUMBER OF
   UNIT CODE                                                         DURATION                  UNITS
                                                                                             REQUESTED
INH.15                 30 Isoniazid 300mg                   300mg once daily x 30 days
RMP.35                 50 Rifampin 300mg                    600mg once daily x 30 days
EMB.55                 60 Ethambutol 400mg                  800mg once daily x 30 days
PZA.65                 90 Pyrazinamide 500mg                1,500mg once daily x 30 days
PYR.71                 30 Pyridoxine 25mg                   25mg once daily x 30 days
INHS                   250mL Isoniazid Syrup                Use as directed.
                       (10mg/mL)
PYR.83                 30 Pyridoxine 50mg                   50mg once daily x 30 days
PYR.97                 30 Pyridoxine 100mg                  100mg once daily x 30 days
RMP.23                 90 Rifampin 150mg                    450mg once daily x 30 days
RMP.21                 30 Rifampin 150mg                    150mg once daily x 30 days
EMB.43                 60 Ethambutol 100mg                  200mg once daily x 30 days
EMB.51                 30 Ethambutol 400mg                  400mg once daily x 30 days
PZA.61                 60 Pyrazinamide 500mg                1,000mg once daily x 30 days

OTHER: Please specify below:




Signature of Nurse ordering these units:                                            Date:


Signature of authorizing Physician:                                                 Date:

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