GET AN IV NOW

GET AN IV NOW is a service for clients of IV Solutions Inc.

Please complete the form below and an IV Solutions client services representatives will contact you within 30 minutes to schedule the service requested. If you do not hear from a client services representative within 30 minutes please call 844-848-8326 and dial ext 1 for our Clinical Services Hotline.

 

CONTACT INFORMATION

Your First and Last Name - (required)

Your Email (required)

Your Phone Number (required)

Your Company/Facility Name (required)

Specialty Facility Code - If N/A select NONE Be certain you are absolutely certain the correct specialty code is selected as this will be where the documentation is routed. Please note Mass General is referred to as MGHAH and Medically Home is often referred to as MHG internally. Be very careful not to confuse these. (required)

PATIENT INFORMATION

Patients Initials - do not use patients full name (required)

Patients street address include City and State (required)

Patients phone number (required)

Allergies - May select multiple - (required)

Allergies Other

PHYSICIAN ORDERS

Is there an active signed licensed independent practitioner order - if no please obtain order before continuing (required)

Service Requested (required)

Please note: If a PICC is requested the following concerns may constitute an automatic change in orders to a Midline or may require you the ordering provider to obtain an order for an x-ray and to followup on the x-ray results (Active AFib or other disqualifying cardiac arrhythmia, Inability to advance the catheter to the Superior Vena Cava during insertion)

A-Fib Aknowledgement (required)

SCHEDULING

Please note our regular hours of operation are Monday - Friday AM8:00 to 5:00PM - any requests outside of normal business hours will be received and responded to the next business day.

Although we will do our very best to see patients at the preferred or requested time, all requests will be scheduled based on geography, clinician availability and patient availability.

Completion of this form does not guarantee services as this form is a request for scheduling.

***** NEW PROCESS - PLEASE READ AND FOLLOW CAREFULLY *****

1) YOU WILL RECIEVE A CONFIRMATION EMAIL... THIS EMAIL ENSURE WE RECIEVED YOUR REQUEST... YOU MUST FOLLOW THE INSTRUCTIONS ON THIS EMAIL TO COMPLETE THE REFERAL

2) YOU MUST EMAIL THE ORDERS AND DEMOGRAPHICS TO RBARNES@NELIFECARE.ORG IMMEDIATELY AFTER SENDING THIS ONLINE REFERRAL FORM

3) YOU MUST CALL 781-281-6942 IMMEDIATELY TO ALERT VASCULAR ACCESS TEAM OF REFERRAL. DO NOT LEAVE A MESSAGE. IF NO ANSWER TEXT "NEW IV ORDERS SENT" TO 781-281-6942... IF YOU DO NOT GET A REPLY OR PERSONALLY HEAR BACK WITHIN 30 MINUTES CALL 781-799-2543 DO NOT LEAVE A MESSAGE. IF NO ANSWER TEXT "NEW IV ORDERS SENT" TO 781-799-2543

Date Requested (required)

Time Preference - Please note (required)

Comments / Notes

To complete this form you must complete all required items and successfully complete the equation below - Once complete and accepted, you will receive a green bar noting your message was successful. Otherwise a red bar with other instructions will appear at the top of the form.