Insertion Request Form | Vic The Picc – Victory Infusion Consultants, Inc

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Insertion Request Form

Phone: 866-971-8422
Fax: 888-723-8422

Documents Required for PICC or Midline Placement
Patient Demographic / Face Sheet
Max. file size: 256 MB.
Physician's Order
Max. file size: 256 MB.
Consent from Patient / Responsible Party
Max. file size: 256 MB.
Download Form
Facility Information
Facility Name*
Date*
MM slash DD slash YYYY
Contact / Nurse Name*
Phone #*
Pharmacy*
State*
State / Province / Region
Patient Information
Patient Name*
First Last
Date of Birth*
MM slash DD slash YYYY
Room #*
Service Info
Service Requested (Select One)*
- PICC
- Midline
- Peripheral IV
- Declot
- Removal
- Port Access
- Other
What medications will be going through the line?*
How Long? / How Often?*
Will the Patient leave the facility for any appointments today what we would need to schedule our nurse around?*
For PICC or Midline Placement Only
Has the Patient had a Mastectomy with or without Lymph Node Involvement?
- YES
- NO
Which side?
Is the Patient on any blood thinners?
- YES
- NO
What is the INR?
Is this Patient a Dialysis or Renal Patient?
- YES
- NO
If so, do you have authorization from Nephrologist to place the line?
Do they have a shunt / fistula / dialysis catheter?
- Shunt
- Fistula
- Dialysis Catheter
- None of the above
If PICC requested, and x-ray required, who will we call for CXR if necessary?
Does the Patient have a Pacemaker?
Does the patient have a history of DVT in either arm?
Does the patient have Atrial Fibrillation?
Is the patient COVID-19 positive or pending results of testing?
- YES
- NO
If so, do you have PPE?
Additional Comments
Additional Comments
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Phone
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ADDRESS
VIC the PICC
1351 E. Pine Street, Suite F
Lodi CA 95240

PHONE
Main: 866-971-8422
Fax: 888-723-8422

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Department*
Email*
Phone*
Message*
Consent*
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I agree that VIC the PICC may contact me by telephone (including cell phones), facsimile, email, SMS or other internet facilities, with respect to employment, education, services, training and other offerings we may make available in the future. Voice and data rates may apply.
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