https://medrxinfusion.com/wp-content/plugins/nex-formsmessageThank you for connecting with us, we will respond to you shortlydefaultH1Orthopedics Referral FormH1Viscosupplementation injections 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 Paragraph2 Cols Date Medication NeededDate Medication NeededHelp text... Ship to:Ship to:PatientPrescriberOtherHelp text... OthersOthersHelp text... Divider Paragraph2 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 allergies:Help text...2 Cols Treatment Diagnosis/Problem(s): Treatment Diagnosis/Problem(s): Help text... Failed therapies reasons:Failed therapies reasons:Help text... Divider Paragraph2 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 H1Prescription InformationH2Injections will be administered in the physician’s office Check BoxesChecbox GroupHyalgan (hyaluronate) 2ml pfsHelp text... Inject 2 ml intoInject 2 ml intoHelp text... knee(s) once weekly forknee(s) once weekly fordoses. DispenseDispensesyringes(s) Divider Paragraph Check BoxesChecbox GroupEuflexxa (hyaluronate) 2ml pfsHelp text... Inject 2 ml intoInject 2 ml intoHelp text... knee(s) once weekly forknee(s) once weekly fordoses. DispenseDispense36 syringes(s)Help text... Divider Paragraph Gel-One (Cross-linked Hyaluronate) 3ml pfsGel-One (Cross-linked Hyaluronate) 3ml pfsGel-One (Cross-linked Hyaluronate) 3ml pfsHelp text... Inject 3 ml intoInject 3 ml intoknee(s) once DispenseDispensesyringes(s) Divider Paragraph Check BoxesChecbox GroupOrthovisc (hyaluronan) 2 ml pfsHelp text... Inject 2 ml intoInject 2 ml intoHelp text... knee(s) once weekly forknee(s) once weekly fordoses. DispenseDispensesyringes(s) Divider Paragraph Check BoxesChecbox GroupSynvisc (hylan G-F 20) 2ml pfsHelp text... Inject 2 ml intoInject 2 ml into knee(s) once weekly for 3 injections DispenseDispense36 syringesHelp text... Divider Paragraph Check BoxesChecbox GroupSynvisc-One (hylan G-F 20) 6ml pfsHelp text... Inject 6 ml intoInject 6 ml into knee(s) once DispenseDispense12 syringe(s)Help text... Divider Paragraph Checbox GroupChecbox GroupSupartz (hyaluronate) 2.5ml pfsHelp text... Inject 2.5 ml intoInject 2.5 ml into knee(s) once weekly forknee(s) once weekly fordose DispenseDispensesyringes(s) Paragraph 3 Cols Date:Date:Help text... Paragraph Paragraph 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