Neurology Referral Form

Infusion Medications

This referral form is provided in order to best serve our patients and prescribers. Patients may choose any pharmacy of their choice.

Complete 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.

Date Medication Needed

Ship to:

Patient

Prescriber

Other

Patient first name:

Patient last name:

Date of birth:

Height:

Weight:

Address:

Allergies/Intolerances:

Phone number(s):

No known allergies:

Treatment Diagnosis/Problem(s):

Prescriber name:

Contact person:

Office Address:

Phone number:

Fax number:

NPI number:

Prescription Information

Solumedrol (methylprednisolone)

in

NS 100 ml

NS 250 ml IV

over 1 hour daily for

days

Novantrone (mitoxantrone): 12 mg/m2 intravenously every 3 months: Contact the MedRx Infusion clinical pharmacist to discuss. Lifetime dosage restrictions, cardiac function tests and other criteria apply.

* TysabriI (natalizumab) is available only through registered infusion centers participating in the TOUCH® Prescribing Program. To locate these infusion centers, contact Biogen Idec at 1-800-456-2255.

* Use the separate form for immunoglobulin therapy. Call MedRx to discuss.

Therapy is going to be administered

physicians office

infusion suite

in patient home

Note: supplies and diluents for physician office and infusion suite use may need to be ordered separately..

Home Health care nursing is needed

to 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.

Med 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.

Patient has an existing intravenous access device (catheter type)

and will require Home Health to maintain the intravenous catheter and MedRx to provide supplies needed

Date:

IMPORTANT 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.