Brooks Heath Care, Inc.

Brooks Health Care, Inc. is a locally owned and operated home infusion and specialty pharmacy provider. BHC also provides respiratory equipment for patients… more

The mission of Brooks Health Care, Inc. is to provide optimum patient centered pharmacy, ambulatory infusion center and respiratory services in the “alternate care” arena, while maintaining a supportive focus on our employees and community.

Online Referral Form

Home Health Agency

Payer

Group Number

Subscriber ID #

Subscriber Name

Medicare #

Medi-cal #

Patient

DOB

Sex

SSN

Emergency Contact

Address

Allergies

Recent Weight Loss

Lbs (3-6 months)

Current Medications

Diagnosis

Medication/Formula

Dose

Therapy Start Date

Duration of Therapy

IV Access

PICC Central IM Heplock

Route of feeding

Bolus

ml/feed

Oral

ml/day

Continuous

ml/day

Respiratory Therapy

CPAP

Nebulizer

Oxygen

Parenteral Nutrition

Brooks Health Care pharmacist to convert to cyclic infusion

Brooks Health Care pharmacist to make recommendations and begin TPN

TPN per attached physician order

Continue current TPN per hospital order

Homecare skilled nursing for administration and teaching

Referred By

Physician Name

Date

Physician Address

Phone Number

License#

UPIN

DEA

Comments/Questions
or other specifications