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Palliative Symptom Relief Kit (SRK) - Cochrane District - Kapuskasing Prescriber Order Form
Procedure:
1. Place your initials and ✪dosing in the column of the table for any medications to be included in the SRK.
2. Fax to Ontario Health atHome at (705-267-7795)
3. Fax to patient’s participating pharmacy of choice:
i. Wal-Mart (855-983-1050)
ii. Shopper’s Drug Mart (705-337-1661)
iii. Rexall (705-337-1877)
4. Family to pick-up SRK & Supplies at dispensing pharmacy.
5. SRK is for short term use only. Prescriptions must be sent for ongoing use for specific medications needed.