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IV TAG

Bottle Number: ______


Name: ________________________ Birthdate: ______________
IV Fluid and Volume: ____________ Rate (ml/hr): ______________
Additive (use red ink): _________________________________
Date Started: _______________ Time Started: _______________
Date Due: _______________ Time Due: _______________
Started by: _______________ Checked by: _______________
CMZ-NDiv.-IVT-0017

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