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XEOMIN® (Standing Order Record Submission)

Date of administration (Required)

Patient details

First name(Required)

LEGAL NAME ONLY

Last name(Required)

Date of Birth(Required)

Medication Details

XEOMIN® 100U Vials (Prscription)

2.5mL Saline 0.9% Dilution

5mL Saline 0.9% Dilution

Did you reconstitute a new vial or existing vial?(Required)

New Vial was made

Existing Vial premade was used

Drug Batch(Required)

Drug Expiry (Required)

Treatment Areas

Treatment Area 1(Required)

Quantity administered (UNITS)(Required)

This must be accurate to ensure correct stock count and as per standing order regulations.

Aministration Method(Required)

Treatment Area 2

Quantity administered (UNITS)

Aministration Method

Treatment Area 3

Quantity administered (UNITS)

Aministration Method

Treatment Area 4

Quantity administered (UNITS)

Aministration Method

Consultation Checklist (Legal Requirements under Standing Order)

Checklist(Required)

All the requirements of the Standing order met.

Patients informed consent was obtained for the treatment

Sterile aseptic technique was used for storage and preparation

Practitioner administering is competent and within scope of practice and identified in the standing order list.

Contraindications and exclusion of standing order list been checked

Indication of treatment "Muscle Relaxing and the treatment of cosmetic appearance of lines/wrinkles"

Clinician Details

Practitioner (Required)

Signature(Required)

THE LABI New Zealand.

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