• Prescriptions for patients who are terminally ill or living in a LTCF will be valid for a maximum period of 60 days. Refills are
not allowed, but the pharmacy may give the patient partial fills of a prescription written for a 60-day supply of fentanyl.
• Prescriptions for patients who are neither terminally ill nor living in a LTCF will require a new prescription before dispensing
each fill. Geneva Woods Infusion Pharmacy will only dispense an appropriate quantity of drug that will fit in one container (bag
or CADD cassette) to eliminate the risk involved with supplying the patient with multiple containers of narcotics to be stored in
• Sodium Chloride 0.9% flush, Heparin flush, and all ancillary supplies per Geneva Woods Pharmacy protocol
• Alteplase 2 mg – instill into each occluded lumen of central line PRN and allow to dwell per manufacturer guidelines x 2 refills
Please fax completed form to Geneva Woods Infusion Pharmacy