https://medrxinfusion.com/wp-content/plugins/nex-formsmessageThank you for connecting with us, we will respond to you shortlydefaultH1Osteoporosis 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 Needed:Date Medication Needed:Help text... Ship to:Ship to:PatientPrescriberOtherHelp text... Text FieldText FieldHelp 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...3 Cols Date of birth:Date of birth:Help text... height:height:Help text... weight:weight:Help text...2 Cols Address:Address:Help text... Allergies/Intolerances:Allergies/Intolerances:Help text...2 Cols Phone number(s):Phone number(s):Help text... No known allergies:No known allergies:Help text...2 Cols Treatment Diagnosis/Problem(s):Treatment Diagnosis/Problem(s):Help text...2 Cols BMD/T Score:BMD/T Score:Help text... Date:Date:Help text... Divider2 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... DividerH1Prescription Information for Subcutaneous Injections Check BoxesChecbox GroupForteo (teriparatide) 2.4ml pfsAdminister 20 mcg subcutaneously once daily 28 day supply for28 day supply formonths Check BoxesChecbox GroupMicalcin (calcitonin) 200 IU/ml 2 ml vialAdminister 100 IU subcutaneously every other day 28 day supply for28 day supply formonths Check BoxesChecbox GroupProlia (denosumab) 60 mg [ ] pfs [ ] vialAdminister 65 mg subcutaneously every 6 months for Administer 65 mg subcutaneously every 6 months forAdminister 65 mg subcutaneously every 6 months formonths DividerH1Prescription Information for Intravenous infusions Check BoxesChecbox GroupBoniva (ibandronate)3mg/3 ml vial PFSAdminister 3 mg intravenously over 15 to 30 seconds q 3 mos. for Administer 3 mg intravenously over 15 to 30 seconds q 3 mos. forAdminister 3 mg intravenously over 15 to 30 seconds q 3 mos. formonths 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: Medication requires that anaphylaxis kit (epinephrine, diphenhydramine) be on hand at home for the first lifetime dose of the intravenous medication 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 device (catheter type)Help text... Text FieldText Fieldand will require Home Health to maintain the intravenous catheter and MedRx to provide supplies needed nous catheter and MedRx to provide supplies needed Dispense the necessary supplies to administer and hazardous waste disposal. Follow guidelines for Calcium and Vitamin D replacementnous catheter and MedRx to provide supplies needed Dispense the necessary supplies to administer and hazardous waste disposal. Follow guidelines for Calcium and Vitamin D replacementHelp text... Paragraph 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
