Check box for Stat Orders
Telephone Order: Write down, Read Back provided to confirm order accuracy
Verbal Order: Emergency only. Repeat Back provided to confirm order accuracy
DATE ________/_______/________ Patient Name :
TIME __________ : _____________ Patient FIN :
AM PM Patient Location:
GENERAL PHARMACY AUTOMATIC SUBSTITUTION ORDER FORM
ORDER WRITTEN : PHARMACY DISPENSED :
Epoetin (Epogen,Procrit™) Darbepoetin (Aranesp™)*Please refer to Aranesp Dose Conversion Table

Order Written : __________________________ ARANESP ________ mg SC Q WEEK
 Ambien® (zolpidem) 10 mg at bedtime or at bedtime prn Ambien® (zolpidem) 5 mg at bedtime or at bedtime prn for insomnia.
May repeat after 1 hour if necessary.
 Ambien CR 6.25mg OR Sonata (zaleplon) 5mg Ambien 5mg po hs
 Ambien CR 12.5mg OR Sonata 10mg Ambien 5mg PO hs prn insomnia. May repeat after 1 hour if necessary
*ALL for po hs prn insomnia
 Allegra® (Fexofenadine) 60 mg po BID Loratadine 10 mg po Daily
 Allegra® (Fexofenadine) 180 mg po Daily Loratadine 10 mg po Daily
 Allegra® D(Fexofenadine/ Pseudoephedrine) Loratadine/Pseudoephedrine 10 mg/240 mg po Daily
60mg/120mg poBID
 Caltrate® D (600 mg elemental) - Any Interval Calcium Carbonate 500 mg+ Vitamin D (Combination) tablet –
Same Interval
 Citracal® (Calcium Citrate 200mg) Tab Calcium Carbonate 1250 mg tablet – Dose = ½ tablet (635mg) OR Calcium
Any Interval Carbonate suspension 1250mg/5ml – Dose = 2.5 ml Same Interval
 Tums® (200 mg elemental) Any frequency  Calcium Carbonate 1250mg tablet ½ tablet same frequency
OR
 Calcium Carbonate suspension 1250mg/5ml = 2.5 ml same frequency
 Clarinex® 5 mg po Daily Loratadine 10 mg po Daily
 Clotrimazole 1% (Lotrimin®) Cream - Any interval Miconazole 2% (Monistat®) Cream - Same interval
 Humalog® (Insulin Lispro) Novolog™ (Insulin Aspart) same dose and frequency
 Humulin-R (Insulin Regular) Novolin-R (Insulin regular) same dose and frequency
 Humulin-N (Isophane Insulin – NPH) Novolin-N (Isophane Insulin – NPH) same dose and frequency
 Novolin 70/30 Humulin 70/30 same dose and frequency
 Fiorinal® (Butalbital 50 mg, ASA 325 mg, Caffeine Fioricet® (Butalbital 50 mg, APAP 325 mg, Caffeine 40mg) same frequency
40mg)
 Macrobid® (Nitrofurantoin) 100 mg BID Nitrofurantoin 50 mg Four Times a Day
 Nystatin (Mycostatin®) topical powder Miconazole (Mitrazol®) topical powder same dose
 Erythromycin Suspension 250 mg PO-Any Interval Erythromycin Ethylsuccinate Suspension 400 mg Po-Same Interval
 Erythromycin Suspension 500 mg PO-Any Interval Erythromycin Ethylsuccinate Suspension 800 mg Po-Same Interval
 Zyrtec® (Cetirizine) 10 mg po Daily Loratadine 10 mg po Daily
 Zyrtec® D 5 mg/120 mg po BID Loratadine/ Pseudoephedrine 10mg/240mg po Daily
Zyrtec® (Cetirizine): Loratadine
 Age 2 to 5 years: 2.5 mg po Daily Age 2 to 5 years: 5 mg once Daily
 Age 6 to 11 years: 5 mg po once Daily Age 6 to 11 years: 10 mg once Daily
EMLA (lidocaine 2.5%, prilocaine 2.5%) cream LMX-4 (lidocaine 4%) cream
1 gram for circumcision in neonates 2 grams for circumcision in neonates

2.5 grams- All other patients-Any frequency 2.5 grams-All other patients-Same frequency

 Accuzyme or Panafil Ointment (Papain, Urea) -Any Frequency Santyl Ointment Apply to affected area ONCE DAILY
Ketorolac (Toradal) – Renal Adjustment - Limited to 5 days of therapy
Patients with a CrCl less than 50 ml/min, or age greater than 65, or weight less than 50 kg
 Ketorolac (Toradol) 60 mg IM X1 Ketorolac (Toradol) 30mg IM X1
 Ketorolac (Toradol) 30 mg IV X1 Ketorolac (Toradol) 15mg IV X 1
 Ketorolac (Toradol) 30 mg IV/IM q 6 hours Ketorolac (Toradol) 15mg IV/IM q6hours (MAX60/24h)
 Ketorolac (Toradol) 20mg PO X1 Ketorolac (Toradol) 10mg po q4h or q6h (MAX 40mg/24h)
followed by 10 mg PO q 4h or q6h
 Renagel® (Sevelamer) 403 mg capsule Renagel® (Sevelamer) 400 mg tablet same interval
 Lumigan (Bimatoprost 0.03%) 1 drop to affected eye(s) Daily HS Xalatan (Latanoprost 0.05%) 1 drop to affected eye(s) Daily HS
(Refer to Therapeutic Substitution List For Below Agents) (Refer to Therapeutic Substitution List For Below Agents)
Actiq Dose :____________ Fentora Dose :_____________
Protonix ® (pantoprazole) 40mg PO/NGT DAILY Nexium® (esomeprazole) 40mg orally/NGT daily

 Prevacid (lansoprazole) : Nexium (esomeprazole) :
 Prilosec (omeprazole) : Nexium(esomeprazole) :
H2 Blockers (Zantac, Axid) : Pepcid (famotadine) :
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Registered Pharmacist: ID# DATE TIME
Physician: ID# DATE TIME
Registered RN : DATE TIME