https://medrxinfusion.com/wp-content/plugins/nex-formsmessageThank you for connecting with us, we will respond to you shortlydefaultH1Immunoglobulin Infusion Therapy 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 Needed:Date Medication Needed:Help text... Delivery location:Delivery location:Help text...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... Phone number(s):Phone number(s):Help text...2 Cols Allergies/Intolerances:Allergies/Intolerances:Help text... no known allergies:no known allergies:No known allergiesHelp text...1 Col Treatment Diagnosis/Problem(s):Treatment Diagnosis/Problem(s):Help text...1 Col Therapy is going to be administeredTherapy is going to be administeredphysicians officeinfusion suitein patients homeHelp text...2 Cols Patient has an existing intravenous access device (catheter type)Patient has an existing intravenous access device (catheter type)Help text... Date PlacedDate PlacedHelp text...2 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... Divider ParagraphIVIG (Intravenous Immunoglobulin(specify product and final % if desired, otherwise the Pharmacist will decide upon the brand/strength based upon the patient’s clinical condition) 4 Cols Dose (grams)Dose (grams)Help text... timestimesHelp text... days/monthsdays/monthsHelp text... mg/kg/daymg/kg/dayHelp text... To be infused intravenously based upon the product package insert recommendations for the product based upon the patient’s weight with the dose tapering up every 30 minutes as tolerated (as assessed by the infusion nurse), with a maximum rate of 200 ml/hr or Text FieldText FieldHelp text... orormy specific infusion rate directions:Help text... directions here.directions here.Help text... The patient should receive the following medications 30 minutes prior to the start of the IVIG infusion:The patient should receive the following medications 30 minutes prior to the start of the IVIG infusion:Ibuprofen 400 mgacetaminophen 650 mg podiphenhydramine 25 mg poHelp text... OtherOtherHelp text... Check BoxesChecbox GroupThe patient may take an additional dose ofHelp text... Text FieldText Fieldevery 4 hours if needed for headache, malaise, body aches ParagraphAnaphylaxis kit (with epinephrine and diphenhydramine, with supplies to administer) on hand for all infusions (see separate anaphylaxis kit approval order) Check BoxesChecbox GroupHome Health care nursing is needed The Home Health nurse will establish the intravenous catheter (peripheral if needed) or otherwise access and maintain the venous catheter, per protocol and stay with the patient during the entire infusion and 30 minutes after completion of the infusion, or as directed by the physician. The RN/LVN will take and record the patient’s baseline vital signs. During the infusion, blood Tel: (310) 671-2600 Fax: (310) 671-2601 Toll Free: (844) 671-2600 Info@medrxinfusion.com MEDRXINFUSION.COM pressure, temperature and respiratory rate are to be monitored and recorded every 15 minutes or as specified by the physician. If there are significant changes out of the normal range or from baseline during the infusion, stop the infusion and notify the physician or pharmacist. ParagraphThe Pharmacy will supply catheter flushing products which may include heparin 100 units/ml, sodium chloride 0.9%, supplies and infusion pump to administer the IVIG..2 Cols DateDateHelp 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
