https://medrxinfusion.com/wp-content/plugins/nex-formsmessageThank you for connecting with us, we will respond to you shortlydefaultH1Rheumatology Referral Form Infusion Medications 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 DateDateHelp text... Ship to: Ship to: PatientPrescriberOtherHelp text... Text FieldText FieldHelp 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 AddressAddressHelp 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... Medications failed and reasons:Medications failed and reasons:Help text... Divider Paragraph 2 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 Check BoxesChecbox GroupActemra (tocilizumab)Help text... mg/kg in NS 50 ml IV over 60 minutes every 4 weeks (start 4 mg/kg and increase up to max of 8 mg/kg based upon response) 4 weeks supply for4 weeks supply formonthsHelp text... Check BoxesChecbox GroupBenlysta (belimumab) 10 mg/kg in NS 250 ml over 1 hr loading doseq 2 wks for 3 doses thenevery wksHelp text... 4 weeks supply for4 weeks supply formonthsHelp text... Check BoxesChecbox GroupOrencia (abatacept)Help text... Text FieldText Fieldmg dose in NS 100 ml IV over 30 minutes Loading dose weeks 0, 2 and 4 then every 4 weeks (weight based dosing mg dose in NS 100 ml IV over 30 minutes Loading dosemg dose in NS 100 ml IV over 30 minutes Loading doseweeks 0, 2 and 4 thenevery 4 weeks (weight based dosing is 500 mg < 60 kg, 750 mg 60 kg – 100 kg, 1000 mg >100 kg)Help text... 4 weeks supply for4 weeks supply formonthsHelp text... Check BoxesChecbox GroupRemicade (infliximab)Help text... Text FieldText Fieldmg/kg in NS 250 ml IV over 2 hrs Loading dose Check BoxesChecbox Groupweeks 0,2 and 6, then everyHelp text... (diagnosis/condition and response dictate the dose and frequency 3 mg/kg up to 10mg/kg, every 4 to 8 weeks) 4 weeks supply for4 weeks supply formonthsHelp text... Check BoxesChecbox GroupRituxan (rituximab) 1000 mg once and repeat in 2 weeks, repeat every 24 weeks (about every 6 months) Help text... 4 weeks supply for4 weeks supply formonthsHelp text... Dilute in NS not less than 250 ml and infusion rate varies. Requires premedication with corticosteroid : list premedications:Dilute in NS not less than 250 ml and infusion rate varies. Requires premedication with corticosteroid : list premedications:Help text... Check BoxesChecbox GroupSimponi (golimumab) 2mg/kg in NS 100 ml IV over 30 minutes week 0, 4 then q8 weekHelp text... 4 weeks supply for4 weeks supply formonthsHelp text... Therapy is going to be administeredTherapy is going to be administeredphysicians officeinfusion suitein patients homeNote: supplies and diluents for physician office and infusion suite use may need to be ordered separately. 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: Note: First lifet ime 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. 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 Paragraph Paragraph 2 Cols Date:Date: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