Medical Referral Form for Vital Infusions

  • Medical Referral Form for Vital Infusions

    Please fill out the form below to refer a patient for home infusion therapy or lab draws using Vital Infusions.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Patient's Date of Birth*
     - -
  • Type of Service
  • Please choose from the following for infusion services:

  • Authorization to Order and Administer Treatment

    By submitting this referral, I hereby authorize Vital Infusions, PLLC, and its designated clinical personnel to: Coordinate the patient's care in accordance with the diagnosis and treatment indicated on this form; Order and/or procure the necessary medications, IV fluids, biologics, vitamins, and/or medical supplies required to safely administer the requested treatment(s); Provide in-home or on-site infusion services under the applicable nursing scope of practice and state/federal regulations. I affirm that the patient has been evaluated and that this treatment is medically appropriate. I understand that Vital Infusions will collaborate with the patient’s pharmacy or medical benefit provider to fulfill product orders and treatment logistics.
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