https://medrxinfusion.com/wp-content/plugins/nex-formsmessageThank you for connecting with us, we will respond to you shortlydefaultH1Gastroenterology Referral Form 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... Help text... Self injection teaching neededPrescriber’s office will teachHelp text... Home Health nurse to infusePrescriber’s ofc. will infuseHelp text... Divider Paragraph 2 Cols Patient first name:Patient first name:Help text... Patient last name:Patient last name:Help text...2 Cols 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... 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 number:NPI number:Help text... Divider Paragraph Check BoxesChecbox GroupCimzia (certolizumab) 200 mgpfsvialsubcutaneously400mg weeks 0, 2 and 4, then 400 mg q4wksStarter Kit (6 x 200 mg pfs)Help text... 4 weeks supply for 4 weeks supply for months Divider Paragraph Check BoxesChecbox GroupHumira (adalimumab) 40 mgpfspensubcutaneously every 2 weeks orHelp text... Help text... 4 weeks supply for4 weeks supply formonths Divider Paragraph Check BoxesChecbox GroupHumira Ulcerative colitis/Crohn’s starter pack for 160 mg on day one (or 80 mg day 1, day 2) then 80 mg in 2 weeksHelp text... 4 weeks supply for4 weeks supply formonths Divider Paragraph Check BoxesChecbox GroupSimponi (golimumab) 100mgpfssmartject subcutaneously 200mg wk 0, then 100 mg week 2, then 100 mg q 4 weeksHelp text... 4 weeks supply for4 weeks supply formonths Divider Paragraph Check BoxesChecbox GroupEntyvio (bedolizumab) 300 mg in NS 250 ml IV over 30 minutesHelp text... Loading doseLoading doseweeks 0, 2 and 6Help text... then everythen everyweeks 4 weeks supply for4 weeks supply formonths Divider Paragraph Check BoxesChecbox GroupRemicade (infliximab)Help text... Text FieldText Fieldper mg/kg in NS 250 ml IV over 2hrs Loading doseLoading doseweeks 0, 2 amd 6 Help text... then everythen everyweeksH5(diagnosis/condition and response dictate the dose and frequency 5 mg/kg up to 10mg/kg, every 8 weeks) 4 weeks supply for4 weeks supply formonths Divider Therapy is going to be administeredTherapy is going to be administeredphysicians officeinfusion suitein patients homeNote: supplies and diluents for physician office and infusion suite use may need to be ordered separately. Check BoxesChecbox GroupHome Health care nursing is neededto infuse medication at home, which may include reconstitution and dilution of the medication according the manufacturer’s or pharmacists instructions, accessing a vein for infusion intravenously, maintaining the intravenous catheter per nursing and MedRx protocol, as well as assessing the patient’s response and tolerance to therapy. ParagraphMed Rx will supply the following for in home infusions: Note: First lifetime doses generally should not be given at home. Consult with the Pharmacist to discuss. Medication requires that anaphylaxis kit (epinephrine, diphenhydramine) be on hand at home for these infusions per MedRx and nursing policy and procedure. Supplies to administer which may include an infusion pump, supplies to maintain venous access, including heparin 100 u/ml flush and sodium chloride 0.9% flush. Check BoxesChecbox GroupPatient has an existing intravenous access deviceHelp text... and will require Home Health to maintain the intravenous catheter and MedRx to provide supplies needed ParagraphDispense supplies necessary for administration and hazardous waste disposal. 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