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Medical Day Care Order Forms
For community providers not on the Epic system.
Thank you for choosing Cooley Dickinson Medical Day Care for your patient. When sending patient orders, please select, download, print and fax the most appropriate order form from the folders below.
When filling out an order form, please:
- Fill out the entire form, including your signature and any Medical Necessity questions.
- Remember to order the primary medication, and any associated pre- or emergency-medications
When faxing order forms:
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Fax to Cooley Dickinson Central Scheduling at 413-582-2183, all of the following:
- The completed order form
- The patient’s current H&P
- A listing of the patient’s current medications & allergies
- Any signed consents that might be required for treatment
If you have any questions, please contact the Cooley Dickinson department that most closely suits your inquiry:
- Central Scheduling: 413-582-5000
- Medical Day Care: 413-582-2920
- Pharmacy: 413-582-2116
Blood transfusions
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Injections and IV therapy
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Medical infusion therapy plan (to be used when specific medication therapy plan being ordered is not available)
Infusions (“therapy plans”)
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