Diabetic Supplies
MD-DIAB-001
Pharmacist-initiated ordering of diabetic monitoring supplies under medical directive
Practice Information
Pharmacy
*
— Select pharmacy —
Implementing Pharmacist
*
— Select pharmacy first —
Site Address
Phone / Fax
Patient Information
Patient Name
*
Date of Birth
*
Phone
Date of Service
Eligibility & Consent
Diabetes Type / Indication
*
— Select —
Type 1 Diabetes
Type 2 Diabetes (on insulin)
Type 2 Diabetes (non-insulin)
Pre-diabetes
Gestational diabetes
Medication-induced hyperglycemia
Weight management with diabetes risk
Intervention Type
*
— Select —
Renewal of existing supplies
Initiation (Type 2 - clinically indicated)
Technology upgrade
Quantity adjustment
Duration (months, max 12)
*
Patient consent obtained — informed of medical directive authorization
⚠ Exclusion Criteria — check any that apply (blocks use of directive)
Patient requires emergency care for DKA / HHS
Patient has refused care / consent
Supply Items
+ Add Supply Item
Clinical Framework
Clinical Rationale
Patient Education Provided
Authorizing Prescriber
from Medical Directive
Prescriber
*
Select prescriber
Designation
Registration
Clinic / FHT
Prescriber Phone
Prescriber Fax
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📄 Prescription PDF
💬 Physician Notification PDF
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