Rheumatology Therapies

Rheumatology Therapies

Complete All Information Below - Once you submit below, your order will be emailed to us and a copy to the contact entered below for your records.
PATIENT DEMOGRAPHIC INFORMATION
Patient Name:*

First NameLast Name
Date of Birth:*

MonthDayYear
Date
Phone #*
Address:*

Address

Street Address Line 2

City/State/ZipState / Province

Postal / Zip Code
Allergies:*
Height:*
Weight:*
Emergency Contact Name:*
Relationship:*
Phone Number*
Please enter a valid phone number.
Diagnosis & Clinical Information

Diagnosis ( ICD 10 Code Required)
Diagnosis:

Arthropathic Psoriasis (L40.50-L40.59)
ICD-10
Rheumatoid Arthritis without Rheumatoid Factor (M06.00-M06.09)Rheumatoid Arthritis with Rheumatoid Factor (M05.70-M05.9)Type Rheumatoid Arthritis, Unspecified (M06.9)
ICD-10
Juvenile Rheumatoid Arthritis (M08.00-M08.99)
ICD-10
Ankylosing Spondylitis (M45.0-M45.9
ICD-10
Systemic Lupus Erythematosus (M32.0-M32.9) Lupus Nephritis
ICD-10
Prior Failed Therapy:
Med Failed
Length of Treatment
Reason for D/C
Med Failed
Length of Treatment
Reason for D/C
Med Failed
Length of Treatment
Reason for D/C
Test Results: Please attach copy for all items checked

Negative TB TestHepatitis B screening test completedCBC w/diff, CMP, Lipid Panel - attach results below
Please include copy of Front and Back of Insurance Card, most recent H&P or MD note, Medication List, and Lab results.
Please upload all information listed above, you can drop and drag multiple files:*

Cancelof
THERAPY ORDERED
Pre-Medications

Acetaminophen: 650mg POCetirizine: 10mg (Zyrtec) PODiphenhydramine: 25mg PODiphenhydramine: 25mg IVPFamotidine: 20mg POMethylprednisolone: 125mg SIVPLoratadine 10mg POOther
MEDICATION DOSE DIRECTIONS/DURATION
Actemra® (tocilizumab)

4mg/kg IV every 4 weeks for _______ doses, followed by 8mg/kg IV every 4 weeks there after X 1 year4mg/kg IV every 4 weeks X 1 year8mg/kg IV every 4 weeks X 1 yearOther
Enter # of Doses
Benlysta® (belimumab)

LOADING: Infuse IV at Weeks 0, 2,and 4MAINTENANCE: Infuse IV every 4 Weeks x 1 year
__________MG (10mg/kg)

Remicade® (infliximab)

	SELECTION	MG
5mg/kg
10mg/kg
Other

	SELECTION	# OF WEEKS
INITIAL: Infuse IV at Weeks 0, 2, and 6
MAINTENANCE: Infuse IV every 8 weeks x 1 year
MAINTENANCE: Infuse IV every____________ weeks x 1 year

Cimzia® (certolizumab pegol)

INITIAL: 400MG Inject 400mg SUBQ at Weeks 0, 2, and 4MAINTENANCE:200mg Inject 200mg SUBQ every 2 weeks x 1 year400mg Inject 400mg SUBQ every 4 weeks x 1 year
Orencia® (abatacept)

<60kg: 500mg 60-100kg: 750mg >100kg: 1000mg INITIAL: Infuse IV at Weeks 0, 2, and 4 MAINTENANCE: Infuse IV every 4 weeks X 1 year
Simponi AriaTM (golimumab)

LOADING: Infuse IV at Weeks 0 and 4MAINTENANCE: Infuse IV every 8 weeks x 1 year
___________MG (2mg/kg)

Renflexis® (infliximab-abda)

	SELECTION	MG
5mg/kg:
10mg/kg:
Other:

	SELECTION	# OF WEEKS
INITIAL: Infuse IV at Weeks 0, 2, and 6
MAINTENANCE: Infuse IV every 8 weeks X 1 year
MAINTENANCE: Infuse IV every ______ weeks X 1 year

Inflectra® (infliximab-dyyb)

	SELECTION	MG
5mg/kg:
10mg/kg:
OTHER:

	SELECTION	# OF WEEKS
INITIAL: Infuse IV at Weeks 0, 2, and 6
MAINTENANCE: Infuse IV every 8 weeks X 1 year
MAINTENANCE: Infuse IV every ______weeks X 1 year

Rituxan® (rituximab)

1000mg Infuse IV on Days 1 and 15 every _________ weeks X 1 year
Enter # of Weeks
OTHER:
OTHER MEDICATION:
Is patient currently receiving therapy above from another facility?*

NOYES
Enter Facility Name
REFERRING PHYSICIAN INFORMATION
Physician Name*
Specialty*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Office Contact*
Contact Email*
Phone #*
Fax #
Please enter a valid phone number.
Comprehensive Support Checklist

Patient Demographic information UploadedFront and Back of Patients Insurance Card UploadedPatient Medication List UploadedSupporting clinical notes including any past tried and/or failed therapies, intolerance, benefits or contraindications to conventional therapy.Most Recent Labs within 3 Mos Uploaded
Signature:*

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Date*

MonthDayYear
Date
InfusaLounge Wellness Spa | 190 E Stacy Rd #1720 | Allen, TX 75002 Phone: 972.546.4318 | Fax: 800.804.4260
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Rheumatology Therapies

PATIENT DEMOGRAPHIC INFORMATION

Diagnosis & Clinical Information

Prior Failed Therapy:

THERAPY ORDERED

MEDICATION DOSE DIRECTIONS/DURATION

REFERRING PHYSICIAN INFORMATION