Download Patient Information (Complete the following or attach patient

Phone: 813-871-5161
Fax: 813-877-2479
Rheumatology
Enrollment Form
PATIENT INFORMATION (COMPLETE THE FOLLOWING OR ATTACH PATIENT DEMOGRAPHIC SHEET)
Male
Patient Name
Female
Allergies
NKDA
Date of Birth
SSN#
Weight ________
Address
City
State
Phone # (Home)
(Work)
kg
lb Date
Zip
Email address(optional)
MEDICAL INFORMATION
Prior Failed Medication (s):
Length of Treatment:
Reason for Discontinuing:
1.
2.
3.
DIAGNOSIS/MEDICAL INFORMATION (PLEASE ANSWER ALL QUESTIONS TO PREVENT A DELAY IN PATIENT’S THERAPY.)
714.0 Rheumatoid Arthritis (RA)
mild
moderate to severe
714.3 Juvenile Idiopathic Arthritis (JIA)
Has the patient had a NEGATIVE tuberculin skin test, or if positive, has therapy for
latent TB been initiated prior to anti-TNF therapy?
yes
no
Other ICD 9 _____________
Does the patient have a clinically important active infection?
yes
no
PRESCRIPTION INFORMATION PLEASE COPY AND ATTACH THE FRONT AND BACK OF INSURANCE AND PRESCRIPTION DRUG CARD
Medication
Dose

Actemra (tocilizumab) 20mg/ml
Forteo  (teriparatide) injection
Cimzia Lyophilized Powder
Cimzia® Pre Filled Syringe
Enbrel (etanercept) PFS
Enbrel (etanercept) SureClick Autoinjector

Orencia (abetacept) Pre-filled Syringe
20mg
40 mg
subcutaneously every other week
__________
IV at 0, 2, & 4 weeks (induction)
IV every 4 weeks (maintenance)
IV every ______ weeks
125 mg inject SQ w/in a day of IV Orencia
Inject 125mg SQ once every week
_________ mg
(Please ensure weight is given
above for dose verification)
3 mg/kg
_____mg/kg
Remicade (infliximab)
(Please fill in weight section)
Rituxan (rituximab)
10 mg/mL, 50 mL vial (500 mg)
Simponi™ (Golimumab)
50mg/ 0.5ml single dose
SmartJect autoinjector
50mg/ 0.5ml single dose PFS
IV at 0, 2 & 6 weeks (induction)
IV every 8 weeks (maintenance)
IV every ______ weeks
Infuse I000 mg IV and follow with a
second dose of 1000 mg IV in 2 weeks
_______________________________
_____ doses
____ doses
_____kits
_____kits
_____vials
4 Syringes
_____vials
4 vials
(2 doses)
_____ vials
_____ doses
Subcutaneously once monthly
60 tablets
Take 5mg twice daily
Tablet
Refills
____ doses
Infuse once every 4 weeks
125mg PFS
Xeljanz
Quantity
subcutaneously every day for 28 days
20mg
subcutaneously every day for _____
Inject 400mg subcutaneously at weeks 0, 2 & 4 (induction)
Inject 400mg subcutaneously every 4 weeks (maintenance)
Inject 200mg subcutaneously every other week (maintenance)
50 mg subcutaneously once weekly
0.8 mg/kg/wk subcutaneously once weekly (JIA) (Please fill in weight section)
___________________
Humira (adalimumab) PFS
Humira (adalimumab) Pen
Orencia (abetacept) Vials
Directions
____ mg
DELIVERY INSTRUCTIONS, PHYSICIAN CONTACT INFORMATION & AUTHORIZATION
Physicians Office
1st dose to MD’soffice, refills to patient home
Patient’s Home
Date Medication
Needed
Address:
Physician Name:
Office Contact:
Institution:
Phone:
Fax:
Specialty: Rheumatology
Address:
City:
License #
NPI #
Physician’s Signature ___________________________________________________________________________ Date _______________________