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Osteoporosis 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

Prescription Information for Subcutaneous Injections

Administer 100 IU subcutaneously every other day

Prescription Information for Intravenous infusions

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: 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.

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

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.