G-Tube and Supra Pubic Intake Form for Nursing Home Facility
Completing this form in its entirety is critical to ensure there are no delays in scheduling the service and that necessary information and equipment are available to facilitate a safe and efficient procedure.
Instructions:
- This form is to be completed by nursing staff. Upon submission the form will be email to cascheduling@ameriwound.com.
- After the form is completed, call 216-273-9800 x….. to confirm receipt of this form. This ensures the form will be prioritized and reviewed for completeness prior to scheduling the patient visit.
G-Tube Equipment Checklist (To be prepared before provider arrival)
Replacement G-tube (same size and type if possible): We will provide:
- Water-soluble lubricant
- 10–20 mL syringes (for balloon inflation and aspiration)
- Sterile water (for balloon inflation)
- pH test strips (or access to aspirate for confirmation)
- Gauze, dressing supplies, gloves
- Saline flushes
Supra Pubic Equipment Checklist (To be prepared before provider arrival)
Replacement tube (same size and type if possible): We will provide:
- Water-soluble lubricant
- 10–20 mL syringes (for balloon inflation and aspiration)
- Sterile water (for balloon inflation
- Gauze, dressing supplies, gloves
- Saline flushes
- Drainage bag