Take Home Form

Patient Name:

Patient Cell Phone:

Intake Name:

CHIPSA Room #:

Departure Date:

Departure time from Hospital:

Out or In Patient? InOut

Does the patient currently have a port? YesNo

Is the patient getting a port when they leave CHIPSA? YesNo

If Yes, Where will he be getting a port?NoneUSACANADAOTHER

If OTHER:

Does the patient want to take port line kits? YesNo

If the patient is getting a port in the States and would like to take port line kits home, just indicate number of port line kits patient will need. Just indicate number of port line kits patient will need.None4 (1 Month)8 (2 Months)12 (3 Months)

If patient DOES NOT have a port and does not plan on getting a port, is patient getting a PICC line when they leave CHIPSA? YesNo

If Yes, Where will he be getting a PICC?NoneUSACANADAOTHER

If OTHER:

If YES. Does patient need PICC line kits or will that be provided through insurance in the states.YesNo

If not provided by insurance in states, THIS REQUIRES A SPECIAL KIT so please indicate patient will need PICC line kits and how many. PICC lines are changed every 7 days so a kit will be needed once a week.None8 (1 Month)16 (2 Months)24 (3 Months)

If patient is NOT getting a PICC line, will patient receive a PIV?YesNo

If patient will have a RN place a PIV every 3-4 days in the States, THIS REQUIRES A SPECIAL KIT so please indicate patient will need PIV kits and how many. PIV are changed every 3-4 days so 2 kits a week are needed. Extra kits should be included in the event the VITCK3 infiltrates and a new PIV is needed. Extra kits should also be provided in the event the RN has a failed attempt. Please indicate how many PIV kits are needed if not provided by patient insurance in the States.None12 (1 Month)24 (2 Months)36 (3 Months)

Take Home Medication Kit:

Additional Medications:

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