<p> PLACE LABEL HERE TUMESCENT INTERVENTIONAL RADIOLOGY ORDERS </p><p>The following orders will be implemented. Orders with a “” are choices and are NOT implemented unless checked. Initial all handwritten order modifications and the bottom of each page when indicated (multipage).</p><p>SCHEDULED MEDICATIONS: </p><p>Tumescent cocktail, using one of the below, to be injected per interventional radiologist during procedure.</p><p> EVLT: Lidocaine 2% inj 30 ml Sodium bicarbonate 8.4% 30 ml In Normal Saline 500 ml or</p><p> Phlebectomy: Lidocaine 2% inj 30 ml Sodium bicarbonate 8.4% 30 ml In Normal Saline 250 ml</p><p>ADDITIONAL ORDERS: ______</p><p>______</p><p>______</p><p>______</p><p>______</p><p>______Date Time Physician Signature PID Number</p><p>Copy to pharmacy </p><p>*1-39374* FORM 1-39374 INITIATED 03/2016 Page 1 of 1</p>