HIV Post-Exposure Prophylaxis Kits Order Sheet

Prescription Template

400 Taché Ave, Winnipeg, MB R2H 2A4
Phone: (204) 233-3469 Fax: (204) 231-1739

Patient

Name

DOBSexMF

PHIN

Phone

Date

HIV Post-Exposure Prophylaxis Kits

Check one

PEP is time-critical: first dose as soon as possible, no later than 72 hours after exposure. Kits are pre-assembled 28-day courses; the pharmacy confirms current kit composition and program eligibility on receipt.

Kit A — standard adult

Kit B — renal impairment

Kit C — older child

Kit D — younger child

Weight (pediatric) kg eGFR if Kit B

Exposure & Timing

Date/time of exposure

First dose given in clinic yes, at no

Patient counselling sheet available at tachepharmacy.com/instructions/hiv-pep and dispensed with each kit on request.

Deliver to clinic yes patient pickup STAT

Prescriber

Name	Clinic
Phone	Fax

Signature