Cabenuva Refill Request
Patient's Name
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First Name
Last Name
Patient's Date of Birth
*
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Month
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Day
Year
Date
What dose of Cabenuva is this for the patient?
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Maintenance, every 2 months (Cabenuva 600/900mg: 3mL CAB + 3mL RPV IM every 2 months)
Maintenance, monthly (Cabenuva 400/600mg: 2mL CAB + 2mL RPV IM once a month)
Restart, every 2 months (Cabenuva 600/900mg: 3mL CAB + 3mL RPV IM once a month x 2 doses then every 2 months thereafter)
Restart, monthly (Cabenuva 600/900mg: 3mL CAB + 3mL RPV IM once. Administer Cabenuva 400/600mg 1 month later.)
When is patient due for injection?
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Month
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Day
Year
Date
When would you like Cabenuva to be delivered to the office?
*
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Month
-
Day
Year
Date
Where would you like the medication delivered?
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Please upload most recent office notes in reference to Cabenuva:
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