Prolia Order & Patient Information Form.pdf

Patient Status:
DOB:
Other Phone:
Allergies:
Weight:
License #:
Address:
City:
Office Contact:
Office phone:
NPI#:
DEA#:
Email:
TIN#:

2. INSURANCE INFORMATION
Please submit copies of the front and back of primary and/or secondary insurance cards with this referral.

3. PHYSICIAN INFORMATION
Select patient referral location:
For new referrals, please include recent labs and last two office visit notes.
Fax completed form to 888-977-0914
Phone: 877-787-8720 • www.horizoninfusions.com

1. PATIENT INFORMATION
4. DIAGNOSIS INFORMATION (and year of diagnosis)
Other:

5. PRESCRIPTION INFORMATION
PROLIA
Administer 60mg/ml via subcutaneous injection
once every six months
Vital signs per HI Protocol
Anaphylaxis & Hydration Management per HI
Protocol
Other

6. LABS
7. SIGNATURE (required)
ICD 10 ()
Quantiferon TB Gold, annually, last completed (date):
Other (specify):
650mg
DATE
Physician Name:
Other Frequency (specify):
Other Frequency (specify):
Other Frequency (specify):
Other Frequency (specify):
Other Frequency (specify):
Other Frequency (specify):
POST-MEDICATIONS
N/A
PRE-MEDICATIONS
1000mg
500mg
Acetaminophen
Fexofenadine (Allegra) 180mg PO (or other non-sedating antihistamine)
IV (requires driver)
Diphenhydrimine (Benadryl)
25mg
50mg
PO
Methylprednisolone (Solu-Medrol)
40mg
80mg
125mg IV
Prednisone mg PO
N/A
Acetaminophen
500mg
650mg
1000mg
Prednisone _ mg PO
Other
Each Infusion
Each Infusion
Each Infusion
Each Infusion
Each Infusion
Each Infusion
Osteoporosis()