Refer a Patient

Please submit this form to refer a patient to The Infusion Center at Denver Arthritis Clinic

PATIENT INFORMATION:

Patient First Name

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Patient Last Name

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Patient's Phone Number

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Patient DOB

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Patient Status:

New to Therapy

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ContinuingTherapy

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Next Treatment Date:

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MEDICAL INFORMATION:

Patient Weight:

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Patient Height:

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Allergies:

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ICD-10:

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Diagnosis

Rheumatoid Arthritis

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Ankylosing Spondyiitis

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Ulcerative Colitis

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Osteoporosis

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Gout

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Thyroid Eye Disease

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Psoriatic Arthritis

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Systemic Lupus Erythematosus

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Crohn’s Disease

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Rheumatoid Arthritis with Rheumatoid Factor

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Multiple Sclerosis Relapsing Remitting

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Plaque Psoriasis

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ANCA vasculitis

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Multiple Sclerosis Primary Progressive

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Others:

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THERAPY ORDER

Actemra

Actemra: 4 mg/kg IV every 4 weeks

Actemra: 6 mg/kg IV every 4 weeks

Actemra: 8mg/kg IV every 4 weeks

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Actemra Other:

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Benlysta

Benlysta: Initial Dose: 10 mg/kg every 2 weeks for 3 doses then every 4 weeks

Benlysta Maintenance: 10 mg/kg every 4 weeks

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Briumvi

Briumvi Loading Dose: 150 mg IV followed by 450 mg IV 2 weeks later then 450 mg every 24 weeks

450 mg IV every 24 weeks

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Cimzia

Cimzia Initial Dose: 400 mg SQ at weeks 0 / 2 / and 4 weeks followed by:

200 mg SQ every 2 weeks

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OR

Cimzia 400 mg SQ every 4 weeks

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Cosentyx

Cosentyx: 300 mg at weeks 0 / 1 / 2 / 3 / 4 followed by 300 mg every 4 weeks

Please select an option.

OR

Weight based

Cosentyx Loading: 6 mg/kg at week 0 followed by 1.75mg/kg (300 mg max) every 4 weeks

Without Loading: 1.75mg/kg every 4 weeks

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Entyvio

Entyvio Initial Start: 300 mg IV at 0 / 2 / 6 then every 8 weeks

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Evenity

Evenity: 210 mg once monthly x 1 year

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Ilumya

Ilumya: Initial Dose: 100 mg SQ at weeks 0 / 4 and every 12 weeks

Maintenance Dose: 100mg SQ every 12 weeks

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Infliximab (Remicade/Avsola/ Renflexis)

Infliximab: Infuse Remicade OR infliximab biosimilar as required by patient’s insurance

Infliximab: Do not substitute. Infuse the following infliximab product:

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Infliximab Dose(mg/kg):

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AND

Infliximab Frequency:

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Infliximab: 0, 2, 6 weeks,

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Infliximab: Every weeks

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Infliximab: Other

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Krystexxa

Krystexxa Dose: 8mg IV every 2 weeks

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Nulojix

Nulojix: Initial phase: IV: 10 mg/kg on day 1 (day of transplant / prior to implantation) and on day 5 (~96 hours after day 1 dose) followed by 10 mg/kg at the end of week 2 week 4 week 8 and week 12 following transplantation

Nulojix: Maintenance phase: IV: 5 mg/kg every 4 weeks beginning at the end of week 16 following transplantation

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Nulojix Other:

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Ocrevus

Ocrevus: Loading Dose: 300mg IV at 0 and 2 weeks then 600mg IV every 6 months

Ocrevus: 600mg IV every 6 months

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Orencia

Orencia: Dose: mg IV (<60 kg: 500 mg; 60 to 100 kg: 750 mg; >100 kg: 1 g)

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AND

Frequency:

Orencia: 0/ 2/ 4 weeks and every 4 weeks

Orencia: Every 4 weeks

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Prolia

Prolia: 60 mg SQ every 6 months

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Reclast (Zoledronic Acid)

Reclast (Zoledronic Acid): 5 mg IV x 1

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Rituximab (Rituxan/Truxima/Rux- ience)

Rituximab (Rituxan/Truxima/Rux- ience): Infuse Rituxan OR rituximab biosimilar as required by patient’s insurance

Rituximab (Rituxan/Truxima/Rux- ience): Do not substitute.

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Rituximab (Rituxan/Truxima/Rux- ience): Infuse the following rituximab product:

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AND

DOSE:

Rituximab (Rituxan/Truxima/Rux- ience): 1000mg

Rituximab (Rituxan/Truxima/Rux- ience): 375mg/m2

Rituximab (Rituxan/Truxima/Rux- ience): 500mg

Please select an option.

AND

Frequency:

Rituximab (Rituxan/Truxima/Rux- ience): One time dose

Rituximab (Rituxan/Truxima/Rux- ience): Day 0 repeat dose in 2 weeks

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Rituximab (Rituxan/Truxima/Rux- ience): then repeat course every weeks

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OR

Rituximab (Rituxan/Truxima/Rux- ience): months

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Rituximab (Rituxan/Truxima/Rux- ience): refill(s)

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Rituximab (Rituxan/Truxima/Rux- ience): Day 0 repeat dose in 2 weeks. One time order do not repeat the course.

Rituximab (Rituxan/Truxima/Rux- ience): Weekly x 4 weeks

Rituximab (Rituxan/Truxima/Rux- ience): Every 6 months x refill(s)

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Rituximab (Rituxan/Truxima/Rux- ience): Other:

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Saphnelo

Saphnelo: 300mg IV every 4 weeks

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Simponi Aria

Simponi Aria: 2mg/kg IV at weeks 0/ 4 and then every 8 weeks (initial dosing)

Simponi Aria: 2mg/kg IV every 8 weeks x 1 year

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Stelara

Stelara: ≤55kg (<120 lbs) 260 mg IV x 1 dose

Stelara: 55kg to 85kg (121 lbs. to 187 lbs.) 390mg IV x 1 dose

Stelara: >85kg (>187lbs.) 520mg IV x 1 dose

Please select an option.

Tepezza

Tepezza: 10mg/kg IV for the first infusion

Tepezza: followed by 20mg/kg IV (3 weeks after the initial dose) every 3 weeks for 7 additional infusions (8 total infusions)

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Vyepti

Vyepti: 100mg IV every 3 months

Vyepti: 300mg IV every 3 months

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Other/Specific Instructions:

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Dose:

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Frequency:

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Premedication orders:

Additional premedications:

Solu-Medrol

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mg IVP

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Solu Cortef

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mg IVP

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Other

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Lab orders:

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Lab frequency:

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PROVIDER INFORMATION

Provider Name:

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Signature:

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Date:

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Provider NPI:

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Phone:

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Fax:

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Contact Person:

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Please upload the requested files

Click to upload files

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I confirm that I have uploaded the clinical chart notes and lab results

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