https://medrxinfusion.com/wp-content/plugins/nex-formsmessageThank you for connecting with us, we will respond to you shortlydefaultH1Rheumatology Referral FormH1(Subcutaneous 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. Divider2 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 teach patient self administrationHelp 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... No known allergies:No known allergies:No known allergies:Help text...2 Cols Phone number(s):Phone number(s):Help text... Date of TB screening:Date of TB screening: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... Office Address: Office Address: Help text...3 Cols Phone number:Phone number:Help text... Fax number:Fax number:Help text... NPI numberNPI numberHelp text... Divider Paragraph H1Prescription Information Check BoxesChecbox GroupActemra (tocilizumab) 162 mg pfs subcutaneously once weeklyHelp text... 4 weeks supply for4 weeks supply formonhtsHelp text... Check BoxesChecbox GroupCimzia (certolizumab) 200 mgpfsvial subcutaneously,400 mg weeks 0,2 and 4, then200 mg q2wks400 mg q4wksStarter Kit (6 x 200 mg pfs)Help text... 4 weeks supply for4 weeks supply formonthsHelp text... Check BoxesChecbox GroupEnbrel (etanercept)25 mg50 mgpfssurclick penvialHelp text... subcutaneouslysubcutaneouslytimes weekly Help text... 4 weeks supply for4 weeks supply formonthsHelp text... Check BoxesChecbox GroupHumira (adalimumab) 40 mgpfspenHelp text... subcutaneously every 2 weeks orsubcutaneously every 2 weeks orHelp text... 4 weeks supply for4 weeks supply formonthsHelp text... Check BoxesChecbox GroupKineret (anakinra) 100 mg pfs subcutaneously dailyHelp text... 4 weeks supply for4 weeks supply formonthsHelp text... Check BoxesChecbox GroupOrencia (abatacept) 125 mg pfs w/saf ndl subcutaneously weeklyHelp text... 4 weeks supply for4 weeks supply formonthsHelp text... Check BoxesChecbox GroupSimponi (golimumab) 50 mgpfssmartject, subcutaneously once a monthHelp text... 4 weeks supply for4 weeks supply formonthsHelp text... Check BoxesChecbox GroupStelara (ustekinumab)45 mg90 mgpfsvialHelp text... subcutaneously Loading dosesubcutaneously Loading doseweek 0 and in 4 weeks, ThenThenmg then once every 12 weeks (dose is weight based) 4 weeks supply for4 weeks supply formonthsHelp text... Dispense supplies necessary for administration and hazardous waste disposal.Dispense supplies necessary for administration 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