https://medrxinfusion.com/wp-content/plugins/nex-formsmessageThank you for connecting with us.defaultH1Dermatology Referral Form 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... Help text... Check BoxesChecbox GroupSelf injection teaching neededPrescriber’s office will teachHelp text... Divider2 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 AddressAddressHelp text... Allergies/Intolerances:Allergies/Intolerances:Help text...2 Cols Phone number(s):Phone number(s):Help text...2 Cols No known allergies:No known allergies: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... Divider2 Cols Prescriber name:Prescriber name:Help text... Contact person:Contact person:Help text...1 Col Office Address: Office Address: Help text...3 Cols Phone number:Phone number:Help text... Fax number:Fax number:Help text... NPI number:NPI number:Help text... DividerH1Prescription Information Paragraph3 Cols Check BoxesChecbox GroupEnbrel (etanercept)Help text... Check BoxesChecbox Group25mg50mgpfssureclick penvialHelp text... Text FieldText FieldHelp text... Text FieldText FieldHelp text...3 Cols Check BoxesChecbox GroupHumira (adalimumab)Help text... Check BoxesChecbox Group40 mgpfspenHelp text... subcutaneously every 2 weeks orsubcutaneously every 2 weeks orHelp text... Text FieldText FieldHelp text... Check BoxesChecbox GroupHumira Psoriasis starter pack pens for 80 mg day 0, then 40 mg day 8, then 40 mg in 2 weeks (the 40 mg q2wks)Help text...3 Cols Text FieldText FieldHelp text...3 Cols Check BoxesChecbox GroupStelara (ustekinumab)Help text... Check BoxesChecbox Group25mg50mgpfspenvialHelp text... Text FieldText FieldHelp text... Text FieldText FieldHelp text...2 Cols Once every 12 weeks (dose is weight based)Once every 12 weeks (dose is weight based)Help text... Help 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