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Refer a Patient

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

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PATIENT INFORMATION:


PATIENT INFORMATION:

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Patient Status:
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MEDICAL INFORMATION:


MEDICAL INFORMATION:

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Diagnosis
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THERAPY ORDER


THERAPY ORDER

Actemra
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Benlysta
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Briumvi
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Cimzia
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OR
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Cosentyx
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OR

Weight based

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Entyvio
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Evenity
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Ilumya
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Infliximab (Remicade/Avsola/ Renflexis)
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AND

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Krystexxa
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Nulojix
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Ocrevus
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Orencia
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AND

Frequency:

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Prolia
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Reclast (Zoledronic Acid)
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Rituximab (Rituxan/Truxima/Rux- ience)
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AND

DOSE:
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AND

Frequency:
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OR
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Saphnelo
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Simponi Aria
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Stelara
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Tepezza
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Vyepti
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Premedication orders:

Tylenol
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Additional premedications:

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PROVIDER INFORMATION


PROVIDER INFORMATION

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