Doctor Referral Form

Name*

First NameMiddle InitialLast NameSuffix
Date of Birth*

MonthDayYear
Phone Number*
Sex*

MaleFemaleOther
Email
example@example.com
Preferred Location
We will also speak with the patient about their preferred location based on where they live.
Sales Rep Referred By:*

Provider Information
Provider Name*
Provider NPI*
Practice Information
Practice Name*
Practice Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Practice Phone Number*
Practice Fax Number*
Contact Person*

First NameLast Name
Contact Person Email*
example@example.com

Referral
Patient Height (ft)

feet* inches*
Patient Height (cm)
Patient Weight (lb)*
Patient Weight (kg)
ICD-10 Codes*
ICD-10 Description
ICD-10 Codes (if applicable, enter multiple by clicking on the "+" icon.
Known Allergies
Medication*
Was the patient prescribed the medicine before?*

Yes, the patient had ben prescribed before.No This is a new medicineOther
When was the last dose?*

MonthDayYear
Date
Abilify (aripiprazole) order*

5.25 mg IM every day for _____ days9.75mg IM every day for _____ days15mg IM every day for _____ daysOther
Actemra (tocilizumab) order*

4mg/kg IV every 4 weeks for ______ doses, then followed by 8mg/kg every 4 weeks thereafter4mg/kg IV every 4 weeks8mg/kg IV every 4 weeksOther
Abilify (aripiprazole) How many days? *
number of days
Actemra (tocilizumab) For how many doses?*
number of doses
Adakveo (crizanlizumab) orders*

5mg/kg IV week 0, 2, and then every 4 weeks5mg/kg IV every 4 weeksOther
Aduhelm (aducanumab-avwa) order*
Initial start w/maintenance dosing (administer every 4 weeks as follows)

1mg/kg for infusions 1 and 2

3mg/kg for infusion 3 and 4

6mg/kg for infusions 5 and 6

10mg/kg for infusions 7 and beyond
Maintenance dose

10mg/kg every 4 weeks
Other
Aralast orders*

60mg/kg IV once a weekOther
Aranesp (darbepoetin alfa) orders*

300mcg subcutaneously every _____ weekOther
Aranesp (darbepoetin alfa) How many weeks? *
Avsola (infliximab-axxq) Order (mg/kg)*
Avsola (infliximab-axxq) Frequency*

0, 2, 6 then every 8 weeksOther
Benlysta (belimumab) orders*
Initial dose

10mg/kg IV at 0, 14 days, 28 days, then every 28 days thereafter
Maintenance dose

10mg/kg IV every 28 days
Other
Bisphosphonate order*

ZometaReclastOther
Zometa order*
mg IV
Zometa frequency*
the prescribed amount every _____ week
Reclast order*
mg IV
Reclast frequency*
the prescribed amount every _____ week
Cerezyme (imiglucerase) orders*

60 mg/kg IV every 2 weeksOther
Cimzia (certolizumab pegol) Please select one:*

Crohn’s DiseasePsoriasisRA/Psoriatic Arthritis/Anklosing Spondylitis/Spondyloarthritis
Cimzia (certolizumab pegol) Crohn’s Disease*

Initial Dose: 400mg subcutaneously at weeks 0, 2, and 4 weeksMaintenance Dose: 400mg subcutaneously every 4 weeks
Cimzia (certolizumab pegol) Psoriasis*

400mg subcutaneously every 2 weeks200mg subcutaneously every 2 weeks400mg subcutaneously at weeks 0, 2, and 4 weeks
Cimzia (certolizumab pegol) RA/Psoriatic Arthritis/Anklosing Spondylitis/Spondyloarthritis*

Initial Dose: 400mg subcutaneously at weeks 0, 2, and 4 weeksMaintenance Dose: 200mg subcutaneously every 4 weeksMaintenance Dose: 400mg subcutaneously every 4 weeks
Cinqair (reslizumab) orders*
Initial dose

3 mg/kg IV every 4 weeks
Other
Crysvita (burosumab) orders*
Adult dose

1mg/kg subQ rounded to the nearest 10mg, every 4 weeks (Max Dose: 90mg)
Pediatric dose

0.8 mg/kg subQ rounded to the nearest 10mg, every 2 weeks (Max dose: 90mg)
Other
Cinqair (reslizumab) note (please checkbox)*
Cubicin (daptomycin) order*

4mg/kg IV Q 24hours for _______days4mg/kg IV Q 48 hours for______days6mg/kg IV Q 24 hours for _______days6mg/kg IV Q 48hours for _______daysOther
Take Cubicin (daptomycin) for how many days?*
Dupixent (dupilumab) order*

600mg SQ* 1 dose300 mg SQ every other weekOther
Elaprase (indursulfase) orders*

0.5 mg/kg IV every weekOther
Elelyso (taliglucerase alfa)*

60 units/kg IV every other weekOther
Elaprase (indursulfase) pre-medications (given 30 minutes prior to infusion)

Tylenol 1000mg POBenadryl 25 mg POOther
Elaprase (indursulfase) Note (please checkbox)*
Entyvio (vedolizumab) orders*
Initial dose

300mg IV at 0, 2, 54, and then every 8 weeks.
Maintenance dose

300mg every 8 weeks
Other
Evenity (romosozumab-aqqg) orders*
210mg subcutaneous injection once monthly.

total of 12 doses
Other
Fabrazyme (agalidase beta) orders*

1 mg/kg IV every 2 weeksOther
Fabrazyme (agalidase beta) pre-medication.

Tylenol 1000mg PO (required)Benadryl 25 mg PO given 30 minutes prior to infusionSolu-Medrol ____mgOther
Fabrazyme (agalidase beta) If selected Solu-Medrol pre-medication, please provide the dosage amount mg*
Feraheme (ferumoxytol) orders*

510mg times 1 dose510mg times 2 dose ___ days apartOther
Feraheme (ferumoxytol) How many days apart?*
Fasenra (benralizumab) orders*
Initial Dose

30mg SubQ every 4 weeks for the first 3 doses, then once every 8 weeks thereafter.
Maintenance Dose

30mg SubQ every 8 weeks
Other
Glassia (Alpha₁-PI)*

60mg/kg IV every weekOther
Glassia (Alpha₁-PI) for how many weeks?*
Number of Weeks
Hemlibra (emicizumab): start with 3mg/kg SQ weekly x 4 doses then:*

1.5 mg/kg SQ weekly3 mg/ kg SQ every one week6mg/kg SQ every 4 weeksOther
Hydration Order*

0.9 NSSD5WD5 0.9 NSSOther
Hydration Dosage*
mL
Hydration Frequency*

____ mL/hourOver ______ hoursOther
Hydration mL*
Hydration Hours*
Hydration (optional) Zofran _____ mg IV * Once
Enter mg/IV
Ilaris (canakinumab) order*

150mg SQ every 4 weeks150 mg SQ every 8 weeksOther
Immunoglobulin (IVIG) Order*

BiviganCivitruGammagardGammunexHizentraOctogamPrivigenOther
Immunoglobulin (IVIG) Will the medication be prescribed in mg/kg or grams?*

mg/kggramsOther
Immunoglobulin (IVIG) Please enter the prescribe dose in the unit you previously selected*
mg/kg or grams
Ilumya (tildrakizumab-asmn) orders*

100mg subcutaneously every 0, 4 weeks than 12 weeks100mg subcutaneously every 12 weeksOther
Kanuma (sebelipase alfa) orders*

1mg/kg IV Q OW x _____ doses3mg/kg IV Q OW x _____ dosesOther
1mg/kg IV Q OW x How many dose?*
1mg/kg IV Q OW x _____ doses
3mg/kg IV Q OW x How many dose?*
3mg/kg IV Q OW x _____ doses
Krystexxa (pegloticase) orders*
8mg IV in 250mL of NS IV over 120 minutes

Frequency: Every 2 weeks

Patient will be observed for 1 hour post infusion
Other
Krystexxa (pegloticase) pre-medications (please checkbox all)*
Lemtrada (alemtuzumab) orders*

12 mg IV daily for 5 days12 mg IV daily for 3 days, 12 months after previous doseOther
Lemtrada (alemtuzumab) Tylenol pre-medication (required)*

500mg PO1000mg POOther
Lemtrada (alemtuzumab) Benadryl pre-medication (required)ritux*

25mg IV50mg IVOther
Lemtrada (alemtuzumab) optional pre-medications

Solu-medrol 1 gram IV on days 1-3 of each courseOther
Lemtrada (alemtuzumab) post-infusion hydration*

500mL NS IV post infusion to run 2 hoursOther
Leqvio (inclisiran) orders*

284mg subcutaneously once then 1 dose 3 months later284mg subcutaneously every 6 monthsOther
Lumizyme (alglucosidase alfa) orders*

20 mg/kg every 2 weeks (4 hour infusion)Other
Lumizyme (alglucosidase alfa) pre-medication

Tylenol 1000mgBenadryl 25mg POSolu-Medrol ______ mgOther
Lumizyme (alglucosidase alfa) If selected Solu-Medrol pre-medication, please provide the dosage amount mg*
Nucala (mepolizumab) orders*
Eosinophilic Asthma

Nucala 100mg subcutaneously every 4 weeks.
Eosinophilic Granulomatosis with Polyangiitis

Nucala 300mg subcutaneously every 4 weeks.
Other
Nulojix (belatacept) orders*

Initial Dose and MaintenanceMaintenance DoseOther
For Nulojix (belatacept) Initial dose & maintenance

mg IV*Day 1 (day of transplantation, prior to transplantation) and Day 5 (approx. 96 hours after Day 1 dose), at the end of week 2, week 4, week 8, and week 12 after transplantation.
Then mg IV* at the end of week 16 after transplantation and every 4 weeks (plus or minus 3 days) thereafter.
* Patient has received number* doses thus far, next dose due on Date* .

***prescribed dose must be evenly divisible by 12.5mg
***The total infusion dose of Nulojix should be based on the patient's actual body weight at the time of transplantation and should not be modified during the course of therapy unless there is a change in the body weight of greater than 10%. If the patient has had >10% weight change, please notify the physician for dose change recommendations.
For Nulojix (belatacept) maintenance dose ONLY
mg IV*mg/IV every 4 weeks.

***prescribed dose must be evenly divisible by 12.5mg
***The total infusion dose of Nulojix should be based on the patient's actual body weight at the time of transplantation and should not be modified during the course of therapy unless there is a change in the body weight of greater than 10%. If the patient has had >10% weight change, please notify the physician for dose change recommendations.
Ocrevus (ocrelizumab) orders*
Initial Dose

300 mg IV at 0 and 2 weeks, then 600 mg IV every 6 months.
Maintenance Dose

600 mg IV every 6 months
Other
Ocrevus (ocrelizumab) pre-medications (checkbox all)
Ocrevus (ocrelizumab) Benadryl pre-medication (required)*

25mg IV50mg IVOther
Ocrevus (ocrelizumab) post-infusion*

Monitor for 1 hour post-infusionNo monitor required post infusionOther
Onpattro (patisiran) orders*

Less than 100kg: 0.30mg/kg IV every 3 weeksMore than 100kg: 30mg IV every 3 weeksOther
Onpattro (patisiran) pre-medications to be given 1 hour before infusion (checkbox all)*
Procrit (epoetin alfa) orders*

20,000 units SQ every _____ weeks40,000 units SQ every _____ weeks60,000 units SQ every _____ weeksOther
Procrit (epoetin alfa) Frequency*
Take the prescribed units SQ every ____ weeks.
Prolastin C liquid order*

60mg/kg IV every one weekOther
Prolia (denosumab) orders*

Prolia 60mg subcutaneous injection every 6 months.Other
Provenge (sipuleucel-T) orders*

50 million cells every 2 weeks x 3 dosesOther
Provenge (sipuleucel-T) pre-medications (please checkbox)*
Provenge (sipuleucel-T) Benadryl dosage*

25mg IV50 mg IV
Provenge (sipuleucel-T) Give patient Famotidine?*

YesNo
Qutenza (capsaicin) orders (max:4)
Note* leave on each area for 60 min, every 3 months or longer
Apply 1 patch to    area of the body
Apply 1 patch to    area of the body
Apply 1 patch to    area of the body
Apply 1 patch to    area of the body
Qutenza (capsaicin) frequency*

Every 3 monthsOther
Radicava (edaravone) orders*
Initial Dose

60mg IV daily for 14 days followed by a 14-day drug-free period.
Maintenance Dose

60mg IV daily for 10 days out of a 14-day period, followed by a 14-day drug-free period for 1 year.
Other
Remicade (infliximab) orders*
mg
Remicade (infliximab) frequency*

Every ____ week0,2,6, then every 8 weeks
Remicade (infliximab) frequency*
mg
Rituxan (rituximab) Medication*

Rituxan (rituximab)Truxima (rituximab-abbs)Ruxience (rituximab-pvvr)Other
Ruxience (rituximab-pvvr) dosage in mg IV *
mg IV
Ruxience (rituximab-pvvr) number of weeks *
every ______week
Truxima (rituximab-abbs) dosage in mg SQ*
mg SQ
Truxima (rituximab-abbs) number of weeks*
every ______week
Rituxan (rituximab) orders*

375mg/m2 Rituxan500mg Rituxan1000mg RituxanOther
Rituxan (rituximab) Frequency*

1 doseDay 0, repeat dose in 2 weeksOther
Rituxan (rituximab) Tylenol pre-medication dosage (mg)*
in mg/PO
Rituxan (rituximab) Benadryl pre-medication IV/PO*

IVPOOther
Rituxan (rituximab) Benadryl pre-medication dosage (mg)*
IV/PO
Simponi Aria (golimumab) orders*
Initial dose

2mg/kg at weeks 0, 4, and then every 8 weeks.
Maintenance dose

2mg/kg every 8 weeks.
Other
Skyrizi (risankizumab) treatment for*

Psoriatic Arthritis and Plaque psoriasisChronsOther
Skyrizi (risankizumab) Psoriatic Arthritis and Plaque psoriasis orders*

150mg SQ week 0 and 4150mg SQ every 12 weeksOther
Skyrizi (risankizumab) Chrons orders*

600 mg IV week 0, 4, 8 followed by
360 mg SQ week 12 then
360 mg SQ Q 8 weeksOther
Soliris (eculizumab) initial dose*
600mg IV weekly for 4 weeks, followed by

900mg IV for the 5th dose 1 week later, then

900mg IV every 2 weeks thereafter.
900mg IV weekly for 4 weeks, followed by

1200mg IV for the 5th dose 1 week later, then

1200mg IV every 2 weeks thereafter.
Other
Soliris (eculizumab) maintenance dose*

900mg IV every 2 weeks1200mg IV every 2 weeksOther
Stelara (ustekinumab) please select one.*

Plaque PsoriasisCrohn’s Disease
Stelara (ustekinumab) Plaque Psoriasis*
Less than 100kg (212lb)

45mg SubQ intially, and 4 weeks later followed by 45mg every 12 weeks
More than 100kg (220lb)

90mg SubQ intially, and 4 weeks later followed by 90mg every 12 weeks.
Other
Stelara (ustekinumab) Crohn’s Disease*
Less than 55kg (121lb):

260mg IV over 1 hour
Between 55kg to 85kg (121lb - 187lb):

390mg IV over 1 hour
More than 85kg (187lb)

520mg IV over 1 hour
Other
Stelara (ustekinumab) maintenance dose*

90mg SQ 8 weeks after initial dose and then every 8 weeks for a year.Other
Tepezza (teprotumamab-trbw) order*

10mg/kg IV for first infusion, followed by 20mg/kg IV every 3 weeks for 7 additional infusionsOther
Tezspire (tezepelumab-ekko) order*

210 mg SQ every 4 weeksOther
Thyrogen (thyrotropin alfa) order*

0.9 mg IM Q 24 hours x 2 doses0.9 mg IM Q 72 hours x 3 dosesOther
Tysabri (natalizumab) orders*

300mg IVOther
Tysabri (natalizumab) frequency*

Once every 4 weeksOnce every 6 weeksOther
Tysabri (natalizumab) how many doses per frequency?*
Ultomiris (ravulizamab-cwvz) orders*

600mg IV x1900mg IV x 11200 mg IV x12400 mg IV x12700 mg IV x13000mg IV x1Other
Ultomiris (ravulizamab-cwvz) Maintainence Dose*

300mg IV Q 2 weeks x1, then Q 4 weeks600mg IV Q 2 weeks x1, then Q 4 weeks2100mg IV Q2 weeks x1, then Q 8 weeks2700mg IV Q2 weeks x1, then Q 8 weeks3000mg IV Q2 weeks x1, then Q 8 weeks3300mg IV Q2 weeks x1, then Q 8 weeks3600mg IV Q2 weeks x1, then Q 8 weeksOther
Uplizna (inebilizumab-cdon) orders*
Initial dose

300mg IV infusion over 90 minutes at week 0 and 2
Maintenance dose

300mg IV infusion over 90 minutes every 6 months for chronic usage
Other
Uplizna (inebilizumab-cdon) pre-medication given 30 minutes prior to infusion (please checkbox)*
Uplizna (inebilizumab-cdon) Benadryl pre-medication*

25mg IV50mg IV
VIBATIV (telavancin) order*

10mg/kg IV Q dayOther
Vivitrol (naltrexone) orders*

380mg IM, given once every month.Other
Vivitrol (naltrexone) dosage*

12 monthsOther
VPRIV (elaglucerase alfa) orders*

360U/kg IV every 2 weeks as a 1 hour infusionOther
VPRIV (elaglucerase alfa) pre-medications

Acetaminophen PODiphenhydramine PO/IVSolu-Medrol IV
VPRIV (elaglucerase alfa) Acetaminophen dose (mg PO)*
VPRIV (elaglucerase alfa) Diphenhydramine dose (mg PO/IV)*
VPRIV (elaglucerase alfa) Diphenhydramine PO/IV*

POIVOther
VPRIV (elaglucerase alfa) Solu-Medrol dose (mg IV)*
Vyvgart (efgartigimod alfa-fcab) order*

10mg/kg IV Q week x 4 doses1200mg IV Q week x 4 (if patients weight more than 120kg)Other
Vyepti (ptinezumab-jjmr) orders*

100mg IV every 3 months300mg IV every 3 monthsOther
Xolair (omalizumab) orders*

150mg225mg300mg375mgOther
Xolair (omalizumab) frequency*

Every 2 weeksEvery 4 weeksOther
Zemaira (Alpha1-Proteinase Inhibitor [Human])*

60mg/kg IV every weekOther
Zinplava (bezlotoxumab) order*

10mg/kg IV x 1 doseOther
Antibiotic orders?
Antibiotic: Vancomycin orders (gms IV)*
Antibiotic: Rocephine orders (gms IV)*
Antibiotic: Invanz orders (gms IV)*
Other antibiotics:*
Refill orders?*

YesNo
Please leave instructions for refill orders*
Any additional comments, pre-medication, or refill orders
Details Need for Authorization
Actemra (tocilizumab) Required Documentation Checklist
Aduhelm (aducanumab-avwa) Required Documentation Checklist
Aranesp (darbepoetin alfa) Required Documentation Checklist
Bisphosphonate Required Documentation Checklist
Cerezyma (imiglucerase) Required Documentation Checklist
Cimzia (certolizumab pegol) Required Documentation Checklist
Cimzia (certolizumab pegol): Has the patient tried another biologic immunomodulator agent that is FDA labeled for this condition?*

YesNo
Cimzia (certolizumab pegol): If the patient is taking another TNF, IL-1 inhibitor, or non-biologic such as infliximab, etanercept, or ankinra, will it be stopped?*

YesNo
Cubicin (daptomycin) Required Documentation Checklist
Entyvio (vedolizumab) Required Documentation Checklist
Evenity (romosozumab-aqqg) Required Documentation Checklist
Feraheme (ferumoxytol) Required Documentation Checklist
Glassia (Alpha₁-PI) Required Documentation Checklist
Hemlibra (emicizumab) Required Documentation Checklist
Ilaris (canakinumab) Required Documentation Checklist
Immunoglobulin Required Documentation Checklist
Illumya (tildrakizumab-asmn) Required Documentation Checklist
Kanuma (sebelipase alfa) Is the patient allergic to eggs/egg products?*

YesNoOther
Krystexxa (pegloticase) Required Documentation Checklist
Flare frequency blanks*.
Lemtrada (alemtuzumab) Required Documentation Checklist
Last MRI Date*

MonthDayYear
Leqvio (inclisiran) Required Documentation Checklist
Lumizyme (alglucosidase alfa) Required Documentation Checklist
Nucala (mepolizumab) Required Documentation Checklist
Nulojix (belatacept) Required Documentation Checklist
Nolojix distribution program - Patient ID
Ocrevus (ocrelizumab) Required Documentation Checklist
Ocrevus (ocrelizumab) Last MRI Date*

MonthDayYear
Date
Ocrevus (ocrelizumab) Date of last:
Refib    Date
Betaseron    Date
Avonex    Date
Tysabri     Date
Procrit (epoetin alfa) Required Documentation Checklist
Prolia (denosumab) Required Documentation Checklist
Provenge (sipuleucel-T) Required Documentation Checklist
Radicava (edaravone) ALSFR Score:
Radicava (edaravone) FVC%:
Remicade (infliximab) Required Documentation Checklist
Simponi Aria (golimumab) Required Documentation Checklist
Simponi Aria (golimumab) Date of last:
Remicade         Date
Actemra    dose   Date
Orencia    dose   Date
Kineret    dose   Date
Humira    dose   Date
Cimzia ebnbrel    dose   Date
Simponi ARIA    dose   Date
Skyrizi (risankizumab) Required Documentation Checklist
Soliris (eculizumab) Required Documentation Checklist
Tepezza (teprotumamab-trbw) Required Documentation Checklist
Thyrogen (thyrotropin alfa) Required Documentation Checklist
Tysabri (natalizumab) Required Documentation Checklist
Tysabri (natalizumab) Last MRI Date*

MonthDayYear
Date
Tysabri (natalizumab) Date of last:
Remicade         Date
Actemra    dose   Date
Orencia    dose   Date
Ultomiris (ravulizamab-cwvz) Has the patient had the menigococcal vaccine (both MenACWY and MenB)?*

YesNoOther
Ultomiris (ravulizamab-cwvz) Is the prescriber enrolled in the Ultomiris REMS program?*

YesNoOther
Uplizna (inebilizumab-cdon) Required Documentation Checklist
Uplizna (inebilizumab-cdon) Is the patient visually impaired?*

YesNoOther
Uplizna (inebilizumab-cdon) Is the patient mobility impaired?*

YesNoOther
Uplizna (inebilizumab-cdon) Does the patient has loss of bladder control?*

YesNoOther
Vivitrol (naltrexone) Required Documentation Checklist
Vyepti (ptinezumab-jjmr) Required Documentation Checklist
Vyvgart (efgartigimond-alfa-fcab) Required Documentation Checklist
Xolair (omalizumab) Required Documentation Checklist
Xolair (omalizumab) History of allergic asthma: Did the patient had positive skin or RAST test(s)?*

YesNoOther
When was the last date the patient had a positive skin/RAST test?*

MonthDayYear
Date
Xolair (omalizumab) Did the patient had pre-treatment of IgE serum?*

YesNoOther
Xolair (omalizumab) IgE serum dose.*
IU/mL
Xolair (omalizumab) When was the last date the patient took IgE serum?*

MonthDayYear
Date
Zemaira (Alpha1-Proteinase Inhibitor [Human]) Required Documentation Checklist
Standard Documentation Required for Most Medications
- Patient demographics
- Patient medical insurance card copied front and back
- Patient pharmacy card copied front and back (if they have one)
- Most recent chart notes, diagnostic testings, and labs.
- Proof of patient being concurrently treated with any other biologics
Please upload any related documentations here:

Cancelof
Authorization & Attestation
Provider Name*
License #*
Provider NPI*
Any Additional comment/note/message for this specific patient
Electronically Signed By*

Clear
Signature
Date of Signature*

MonthDayYear
Date
Should be Empty:

Provider Information

Practice Information

Referral

Details Need for Authorization

Authorization & Attestation