IVIG Order Form
…Please fax form to: 405-726-9849…
Please fax form to: 405-726-9849
Patient Information
Patient Name:
DOB:
Phone:
Gender:
M F
Patient Address:
Email:
Insurance:
Additional Information Needed
Fax front/back of insurance card
Fax patient demographics
Fax clinical/progress notes
Fax current medication list
Fax labs
Fax TB and Hep B results
Diagnosis and Clinical Information
Diagnosis (ICD-10):
D69.3 Immune Thrombocytopenic Purpura D80.9 Immunodeficiency with Predominantly Antibody Defects, Unspecified
D81.9 Combined Immunodeficiency, Unspecified D83.9 Common Variable Immunodeficiency, Unspecified
G61.81 Chronic Inflammatory Demyelinating Polyneuritis G61.82 Multifocal Motor Neuropathy
Other: Code: __________ Description: ______________________________________________________________________________
Clinical Information:
New Therapy Induction Therapy Change Therapy Continuation
Patient Weight: __________ lbs / __________ kg Patient Height: __________ in / __________ cm
Allergies: ______________________________________________________________________________________________________
Therapies Tried and Failed: _______________________________________________________________________________________
TB Test: Date: __________ Results: ____________________ Hep B Test: Date: __________ Results: ____________________
Lab Orders Lab Orders to be done by
CBC CMP ESR CRP HBsAg HBsAB HBcAB Quantiferon Gold
Other: ____________________________________
Oklahoma Infusion Services
Referring Provider
Prescription Information
Gammagard
Liquid 10%
Dose: _____ mg/kg
Frequency: every ___ weeks for ___ months
Dose: _____ g/kg/month
Frequency: every ___ weeks for ___ months
Privigen 10% Dose: _____ mg/kg
Frequency: every ___ weeks
Dose: 1g/kg
Frequency: for 2 consecutive days
Initial Dose: 2g/kg in divided doses over ___
consecutive days
Maintenance Dose: 1g/kg in ___ infusions
on consecutive days, every 3 weeks
Other Medication: ____________________ Dose: ____________________ Frequency: _____________________
☒ Solu-Cortef 50-100mg SIVP
☒ Tylenol tablet 500-1000mg PO PRN
☒ Benadryl 25mg PO PRN
☐ Other: ______________________________________________
Standing Orders for Adverse Reactions
☒ Stop infusion and initiate NS bolus
☒ Notify supervising physician and ordering provider
☒ Solu-Cortef 100mg SIVP signs of adverse reaction
☒ Benadryl 25mg SIVP for hives or bronchial inflammation
☒ Epi 1:1000 1mL IM, IV, or SQ for anaphylaxis
☒ Oxygen 2-5L nasal cannula
☒ Albuterol 2.5mg inhaled PRN for chest tightness
☐ Other: ______________________________________________
Prescriber Information
Prescriber Name: Office Contact Name:
NPI #: DEA #: Contact Phone: Contact Fax:
_____________________________________________________________________________ ____________________________________
Prescriber’s Signature: Date:
By signing this form, you are authorizing Oklahoma Infusion Services and its employees to act as your designated agent to interact with medical and prescription insurance
companies for prior authorization and specialty pharmacy approval to render infusion services.
Pre-Medication Orders
