Oncology Referral Form

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

Self injection teaching needed

Prescriber’s office will teach patient self administration

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:

Provide chemotherapy protocol with medication orders, including doses and adjuncts

This is cycle #

of

cycles,

cycle length (days or weeks)

Therapy is going to be administered

physicians office

infusion suite

in patients home

Home Health care nursing is needed

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 including NaCl 0.9% flush and Heparin 100units/ml flush per nursing and pharmacy protocol.

Prescription Information for Hemopoetic growth factors for chemotherapy

Filgrastim (Neupogen)

vial

pfs

subcutaneously daily for
days

starting

Pegfilgrastim (Neulsta) 6 mg pfs

subcutaneously on day

of week

of chemotherapy cycle starting

Epoetin (Procrit, Epogen) via

units subcutaneously

(frequency) for

days,

starting

Darbepoetin (Aranesp* )

via

pfs

mcg

subcutaneously every

weeks for

weeks,

starting

*Prescriber must be enrolled in ESA APPRISE Oncology Program”

Romiplostim (Nplate)

250 mcg vl

500 mcg vl

Give

mcg subcutaneously every 7 days, for

doses

Dispense supplies necessary for administration and hazardous waste disposal.

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.