https://medrxinfusion.com/wp-content/plugins/nex-formsmessageThank you for connecting with us, we will respond to you shortlydefaultH1Multiple Sclerosis Referral FormH1(Subcutaneous/IM injections) Paragraph Divider ParagraphThis referral form is provided in order to best serve our patients and prescribers. Patients may choose any pharmacy of their choice. Divider ParagraphComplete patient demographics below or otherwise provide the information requested along with this referral form. Also needed: 1) Patient insurance information (front and back of card) 2) History and physical, chart notes, laboratory results and other diagnostic tests needed to support the use of this medication 3) patient’s medication history related to their current diagnosis/problem. Divider Paragraph 2 Cols Date Medication NeededDate Medication NeededHelp text... Ship to:Ship to:PatientPrescriberOtherHelp text... Text FieldText FieldHelp text... Check BoxesChecbox GroupSelf injection teaching neededPrescriber’s office will teachHelp text... Divider Paragraph 2 Cols Patient first name:Patient first name:Help text... Patient last name:Patient last name:Help text...3 Cols Date of birth:Date of birth:Help text... height:height:Help text... weight:weight:Help text...2 Cols Address:Address:Help text... Allergies/Intolerances:Allergies/Intolerances:Help text...2 Cols Phone number(s):Phone number(s):Help text... No known allergies:No known allergies:Help text...2 Cols Treatment Diagnosis/Problem(s):Treatment Diagnosis/Problem(s):Help text... Failed Medication with reasons:Failed Medication with reasons:Help text... Divider Paragraph 2 Cols Prescriber name:Prescriber name:Help text... Contact person: Contact person: Help text... Address:Address:Help text...3 Cols Phone number:Phone number:Help text... Fax number:Fax number:Help text... NPI number:NPI number:Help text... Divider Paragraph H1Prescription Information Check BoxesChecbox GroupAvonex (interferon beta-1a)autojectpfs30 mcg intramuscularly once weeklyAvostartgrip (for pfs) titration kit for induction doses 7.5 mcg week 1, 15 mcg week 2, 22.5 mcg week 3 Help text... 4 weeks supply for4 weeks supply for(months)Help text... Check BoxesChecbox GroupBetaseron/Extavia (interferon beta-1b) 3 mg pfs 0.25 mg subQ every other dayHelp text... 28/30 day supply for28/30 day supply formonthsHelp text... CopaxoneCopaxoneCopaxone (glatiramer) 20 mg pfs20 mg subcutaneously every dayHelp text... 30 day supply for30 day supply formonthsHelp text... Check BoxesChecbox GroupBetaseron/Extavia induction schedule (0.0625 mg to 0.25 mg subQ every other day)Help text... 28/30 day supply x 1 month28/30 day supply x 1 monthHelp text... Check BoxesChecbox GroupCopaxone (glatiramer) 20 mg pfs20 mg subcutaneously every dayHelp text... 30 day supply fo30 day supply fomonthsHelp text... Check BoxesChecbox GroupCopaxone (glatiramer) 40 mg pfs40 mg subQ 3 times weekly (at least every 48 hrs)Help text... 4 weeks supply for4 weeks supply formonthsHelp text... Check BoxesChecbox GroupPlegridy (peginterferon beta-1a)penpfs125 mcg subQ every 14 daysHelp text... 4 weeks supply for4 weeks supply formonthsHelp text... Check BoxesChecbox GroupPlegridy (peginterferon beta-1a) Induction packpenpfs 63 mcg subQ day 1, 94 mcg subQ day 154 weeks supply Check BoxesChecbox GroupRebif (interferon beta-1a)pfs 63 mcg subQ 3 times weekly (atleast every 48 hrs.)Help text... 4 weeks supply for4 weeks supply formonthsHelp text... Check BoxesChecbox GroupRebif titration pack:Help text... Indicate induction scheduleIndicate induction schedule4 weeks supply x1 month Dispense the necessary supplies to administer and hazardous waste disposal.Dispense the necessary supplies to administer and hazardous waste disposal.Help text... Paragraph Paragraph 2 Cols Date:Date:Help text...H4IMPORTANT NOTICE: This form my contain confidential and privileged information and is only intended only for the person named herein. If you are not the named addressee, do not disseminate, distribute or copy this form or any of its contents. Please notify the sender immediately if you have received this document by mistake, then destroy this form. Submit ButtonSubmit