Doctor IV Infusion

Outpatient Infusion Order Forms

This page is intended for community providers who do not have access to Providence Epic and need to submit outpatient infusion orders by fax. Providers can use the downloadable Outpatient Infusion Order Fax Guide to find clinic locations, phone and fax numbers, and hours of operation.

For Providence providers with Epic access, outpatient infusion orders should be entered through the appropriate infusion therapy plan. Faxed orders are accepted only from external clinics that do not use Providence Epic.

Our infusion therapies include the following (subject to change, may not be available at all locations):

  • Antibiotics
  • Blood products
  • Bisphosphonates
  • Chemotherapy and Immunotherapy
  • Hydration and IV antiemetics
  • IM and SQ injections
  • IV medications
  • Peripheral and central line management

Order Forms

Download and print the appropriate order form below. Please be sure to fill out all sections, sign the order, and fax to the appropriate site listed on the form.