Please Check off any medications below, you are authorizing our Nurses to refill after-hours:

(RN will check for allergies. Rx will be contraindicated if any history of eye trauma)

Nurse Practitioner 2nd Tier Coverage

Please indicate whether your practice is interested in Nurse Practitioner 2nd Tier Coverage, to reduce On-Call MD consults.

Potential Applications of NP Coverage/RN to NP Consults:

Lab/Xray Results*Chronic Disease Exacerbation*Premature Infant Consults*Medication Change Requests/Pharmacy Clarification/Substitution*Formula Change Requests*New Rx-Order Not Received by Pharmacy*New Rx Requested (e.g., Antibiotics for suspected UTI, OM; Steroid:Poison Ivy, Croup, Asthma)*Caller Declines Go to ER Instruction/Protocol-Notification*Practice Requires Prior ER Auth* Urgent Care Required-Office Opening in Next 90 Minutes*Caller Requests to Speak with MD* Patient Not Improved After Recent OV or ER Evaluation*Solo Practice MD/On-Call Coverage*Holiday/Vacation/PRN On-Call Coverage*Urgent Tele-Medicine Evaluation*Next Day Urgent Tele-Medicine Evaluations

Survey: How Can We Help You More?

In expanding our line of service, what else can we provide you/your practice to improve our service?

Is there anything you recommend our RNs do differently, to make your coverage experience better?

Is our management answering inquiries and any concerns promptly and thoroughly to your satisfaction?

If you could change any aspect about being On-Call, what would it be?

What do you like best and least about Night Nurse triage service coverage?

Any other feedback?