Medication Dose/Strength Directions Quantity Refills
Leuprolide Two Week Kit
(10) Extra ½cc Insulin Syringes
1 mg/0.2 mL
Sig: ___________________________________
Follistim AQ Cartridge
PEN
300 IU 600 IU 900 IU
Inject as directed. <Up to ________ units per day>
Gonal-f RFF Pen: 300 IU 450 IU 900 IU
Inject as directed. <Up to ________ units per day>
Gonal-f MDV: 450 IU 1050 IU
Inject as directed. <Up to ________ units per day>
Menopur 75 IU
Inject as directed. <Up to ________ units per day>
Ganirelix PFS 250 mcg/0.5 mL
Inject #_____ PFS SQ QD
Cetrotide Kit 0.25mg
Mix & Inject #_________ SQ QD
Pregnyl 10,000 IU
Mix with ____ mL and inject ______ units/mL when directed (IM) (SQ)
Novarel 5,000 IU
Mix with ____ mL and inject ______ units/mL when directed (IM) (SQ)
Ovidrel PFS 250 mcg/0.5 mL
Inject # _____ PFS when directed
Estrace Tablets 0.5mg 1mg 2mg Titrate up to ____ tab(s) per day as directed PO PV
Vivelle Dot 0.1mg/24 hr (#8/Box)
Use as directed up to # ________ patch(es) every _____ day(s)
Doxycycline Capsules 100mg
Take 1 capsule by mouth BID
Medrol Tablets 4mg 8mg 16mg
Take ______ tab(s) ______ times a day for _______ day(s)
Progesterone 50mg/mL in
Sesame Oil
Indicate here if Compound Ethyl
Oleate is required
Inject _________ mL(s) __________ times a day
Endometrin Vaginal Inserts 100mg
Use 1 insert PV _______ times a day
Crinone 8%
Use 1 appl PV _______ times a day
Progesterone Capsules 100mg 200mg
Use _______ cap(s) (PO / PV) __________ times a day
Other
Other
Other
Infertility Enrollment Form
PATIENT INFORMATION PRESCRIBER INFORMATION
Prescriber’s Name
Address
City, State, ZIP
Office Contact
Phone Fax
DEA NPI
ICD-10 Code Description
Allergies Concomitant Medications
MEDICAL INFORMATION (Section must be completed to process prescription) (Attach separate sheet if needed)
CONFIDENTIALITY STATEMENT: This communication is intended for the use of the individual or entity to which it is addressed and may contain information that is privileged, confidential, and exempt from disclosure under applicable law. If the reader
of this communication is not the intended recipient or the employee or agent responsible for delivery of the communication, you are hereby notified that any dissemination, distribution, or copying of the communication is strictly prohibited. If you have
received this communication in error, please notify us immediately by telephone. This form is not a valid prescription in Arizona.
Address
City, State, ZIP
Patient Name
Please complete the following or send patient demographic sheet
Diagnosis – Please include diagnosis name with ICD-10 code
Gender
Last Four of SS#DOB
Home Phone Alternate Phone
PRESCRIPTION INFORMATION
* Prescriber Authorization: I authorize this pharmacy and its representatives to act as my authorized agent to secure coverage and initiate the insurance prior authorization process for my patient(s), and to sign any necessary forms on my
behalf as my authorized agent, including the receipt of any required prior authorization forms and the receipt and submission of patient lab values and other patient data. In the event that this pharmacy determines that it is unable to fulfill
this prescription, I further authorize this pharmacy to forward this information and any related materials related to coverage of the product to another pharmacy of the patient’s choice or in the patient’s insurer’s provider network.
Language Preference: English Spanish Other
INSURANCE INFORMATION (Must fax a copy of patient’s insurance card including both sides)
Plan Name
Prior Authorization Reference Number
BIN PCN Group Cardholder ID
Ship to:
Patient
Office
Other Date Needs by Date
Prescriber’s
Signature Date
08042161397
Product Substitution Permitted (Product will be
substituted if DAW not indicated)
Dispense as Written
Supervising
Physician
Signature Date
Faxed by:
Donor
I.P.
G.C.
Fertility Phone: 877-358-9016
Fax: 844-234-1361
Specialty Pharmacy Enrollment Form
Please detach before submitting to a pharmacy – tear here.
Electronic or digital signatures not accepted.
This form is not a valid prescription in Arizona
