Depo Provera Order Form Date: _____

Depo Provera Order Form

Date: ________

Health Service

507-933-7630 phone * 507-933-6074 fax

Paent Label

TO BE COMPLETED BY ORDERING MEDICAL PROVIDER:

Please complete all of the following:

□ Original RX DX: ________ Start date: __________ Stop date: __________ Rells: _________

□ Date of last injecon: _________________________ Injecon site: _____________________

□ Next injecon due: _________________________

Please fax any supporng documents to Gustavus Health Service, 507-933-6074 (fax).

Ordering Provider Signature: __________________________________________ Date: __________

TO BE COMPLETED BY PATIENT:

Purpose for disclosure: X Connuaon of Medical Care

I understand that the informaon in my health record may include informaon relang to sexually trans-

mied disease, acquired immunodeciency syndrome (AIDS), or human immunodeciency virus (HIV). It may

also include informaon about behavioral or mental health services, and treatment for alcohol and drug

abuse.

As stated in the Noce of Privacy, I understand that I have a right to revoke this authorizaon at any me. I

understand that if I revoke this authorizaon I must do so in wring and present my wrien revocaon to

Gustavus Adolphus College Health Service. I understand that the revocaon will not apply to informaon

that has been already released in response to this authorizaon. I understand that the revocaon will not

apply to my insurance company when the law provides my insurer with the right to contest a claim under my

policy. Unless otherwise revoked, this authorizaon will expire on the following date, event, or condion:

_________________. If I fail to specify an expiraon date, event or condion, this authorizaon will expire in

one year. I understand that authorizing the disclosure of this health informaon is voluntary. I can refuse to

sign this authorizaon. I need not sign this form in order to assure treatment. I understand that I may inspect

or copy the informaon to be used or disclosed, as provided in CFR 164.524. I understand that any disclosure

of informaon carries with it the potenal for an unauthorized disclosure and the informaon may not be

protected by federal condenally rules. If I have quesons about disclosure of my health informaon, I can

contact the Gustavus Adolphus College Health Service.

_________________________________________________ __________________

Signature of Paent Date

If paent is not able to sign, please indicate relaonship to paent:

□ Parent of Minor □ Legal Guardian □ Other

ID Vericaon _________________________________ Completed by __________________ Date ____________