Remicade/Infliximab Order Form
(Infliximab)
Referral Order Type
*
New Referral
Restart
Medication Order Change
Continuing Treatment
Patient Information
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
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Email
*
Physician Information
Referring Physician
Practice Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Office Contact Name
Contact Phone #
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Fax#
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NPI / TIN
Medication Orders
Patient Weight:
*
kg
Initial/Reload Dosing:
mg/kg IV at 0, 2, and 6 weeks.
Maintenance Dosing:
mg/kg IV every
weeks.
Other:
Premeds:
Diphenhydramine
Famotidine (IV)
Hydrocortisone
Indication / Diagnosis:
*
K50.90 Crohn's disease, unspecified, without complications
K51.90 Ulcerative colitis, unspecified, without complications
L40.59 Other psoriatic arthropathy
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
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MD Signature
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Date
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-
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Date
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