Avsola® Order Form
(infliximab-axxq)
Referral Order Type
*
New Referral
Medication Order Change
Restart
Continue Treatment
Patient Information
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Patient Insurance Information
Physician Information
Practice Name
Referring Physician
*
Practice Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Office Contact Name
*
Contact Phone #
*
Please enter a valid phone number.
Fax#
*
Please enter a valid phone number.
NPI
*
TIN #
*
Medication Orders
Patient Weight:
*
Initial/Reload Dosing:
mg/kg IV at 0, 2, and 6 weeks.
Maintenance Dosing:
mg/kg IV every
weeks.
Other:
Premeds:
Benadryl
Famotidine (IV)
Hydrocortisone
Other
Indication / Diagnosis:
*
K50.90 Crohn's disease, unspecified, without complications
K51.90 Ulcerative colitis, unspecified, without complications
M05.79 Rheumatoid arthritis with rheumatoid factor without organ or systems involvement
M06.09 Rheumatoid arthritis without rheumatoid factor, multiple sites
M06.9 Rheumatoid arthritis, unspecified
M45.9 Ankylosing spondylitis of unspecified sites in spine
L40.59 Other psoriatic arthropathy
Other, specify:
Required Documentation
Upload Most Recent office & consult notes (must include discussion of prescribed drug)
*
Upload Most Recent office & consult notes
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of
Current Medication List & Labs
*
Current Medication List & Labs
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If continuing treatment, most recent infusion note.
*
If continuing treatment, most recent infusion note.
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of
Prescriber Signature
*
Date
*
-
Month
-
Day
Year
Date
Submit
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