Attachment_J-__GTube_Feed_Authorization_Form_(Contractor_Owned_Developed).pdf

G-TUBE FEEDING AUTHORIZATION FORM

Instructions: This form is to provide medical and parental authorization for Tube feeding treatment to be provided while the EFM is receiving respite care. Both the Physician and Parent/Legal Guardian portions of this authorization form must be completed entirely, signed, and returned to Strategic Resources, Inc. before the treatment may be administered.

Student’s Name Sex Date of Birth Age

Address Phone Number(s) Email Address

The following section is to be completed by the prescribing Physician:

The child named in this document is under the medical supervision for the diagnosis described below. I have prescribed the following treatment, which is necessary to be given during the primary caregiver’s absence. I am aware that this physician prescribed service may be administered by non-medically trained staff.

Diagnosis for which tube feeding will be required:

Allergies:

Type of Gastrostomy PEG Button G-Tube Other (describe)

Appliance placed:

Tube feeding formula:

Amount of tube feeding:

Tube flush: Amount of tube Flush solution:

Time and frequency of feedings:

Is it necessary to If yes, will the residual content alter feeding If yes, please indicate the residual

Measure residual volume? amount that would prohibit feeding at

Stomach contents? No Yes the prescribed time: cc total

No Yes volume.

Tube feeding method: Bolus by gravity Mechanical Pump

Bag Type of pump

Syringe Rate of flow cc/hr.

Physician’s name: Phone number:

Physician’ signature: _____________________________________________________________________Date:

Parent’s name: ___________________________________________________Phone number:

Parent’s signature: ______________________________________________________________________Date: ________________________

Attachment J