IG Sub-Q Injection Referral Form

www.soleohealth.com
Phone: 866.923.4495
IG Sub-Q Injection Referral Form
Please complete the following and fax with clinical documentation to 866.923.4492
Easy 6-Step Referral Process
1. PATIENT INFORMATION
2. PHYSICIAN INFORMATION
Name:
Physician’s name:
Address:
License #:
City:
State:
Zip:
Home Phone:
Secondary Phone:
DEA #:
Address:
Email:
DOB:
City:
/
/
Gender: ☐Male ☐Female
Social Security #:
Height:
NPI #:
State:
Zip:
Office Contact:
Phone :
Weight:
Fax:
Allergies:
3. INSURANCE INFORMATION
ICD-9 Diagnosis Code:
Please submit copies of the front and back or primary and
secondary insurance cards with this referral.
Years with Disease:
Current Therapy:
4. TREATMENT SETTING & PATIENT TRAINING
a. Treatment Setting: ☐ Physician’s office ☐ Home infusion RN ☐ Begin in clinical setting transitioning to home
b. Patient Training In Home: ☐ Yes ☐ No
5. PRESCRIPTION INFORMATION
☐ Hizentra®
Convert monthly IVIg dose in grams to weekly IVIg dose. Example: Your patient is currently receiving 40 g of IVIg once every 4 weeks.
Example - 40 g / 4 = 10 g
Your Calculations: __________ g / __________number of weeks between IVIg doses = __________ weekly IVIg dose in grams
Convert weekly IVIg dose in grams to weekly Hizentra dose in grams Example - 10 G x 1.53 = 15.3 g
Your Calculations: __________ g x 1.53 = __________ weekly
RX: Total Weekly Dose: __________ in grams x by 5 = ________ Total mL. Dispense 4-week supply = __________mL with _________refills
Dispense in combination of single-use vial sizes to equal total mL prescribed for each dose. May be rounded to next vial size.
Available in: 1gm-5ml, 2gm-10ml, 4gm-20ml.
Premedication: ____________________________________________ Additional Instructions:________________________________________
☐ Gamunex-C®
Order Calculation for Sub-Q Injection 1.37 X current IV dose in mg/kg/IV dose interval in weeks Infusion Rate = 20ml/hr/site
Your Calculations: 1.37 x __________ mg/kg IV.
RX: Total Weekly Dose: _________ grams ___________Total mLs. Dispense 4-week supply with__________ refills
Dispense in combination of single use vial sizes to equal total ml prescribed for each dose. May be rounded to next vial size.
Available in: 1gm-10ml, 2.5gm-25ml, 5gm-50ml, 10gm-100ml and 20gm-200ml
Premedication:______________________________________________ Additional Instructions:_______________________________________
☐ Gammagard® Liquid
Order Calculation for Sub-Q Injection: Initial Dose is 1.37 x previous IV dose divided by # of weeks between IV doses.
Initial Infusion Rate:
40 kg BW and Greater: 30 mL/site at 20 mL/hr/site
Under 40 kg BW: 20 mL/site at 15 mL/hr/site
Maintenance Infusion Rate:
40 kg BW and Greater: 30 mL/site at 20 to 30 mL/hr/site
Under 40 kg BW: 20 mL/site at 15 to 20 mL/hr/site
RX: Total Weekly Dose: __________ in grams = __________ Total mL. Dispense 4-week supply with __________ refills
Dispense in combination of single-use vial sizes to equal total mL prescribed for each dose. May be rounded to next vial size.
Available in: 1.0gm-10ml, 2.5gm-25ml, 5.0gm-50ml, 10gm-100ml, 20gm-200ml, 30gm-300ml
Premedication: ____________________________________________ Additional Instructions:______________________________________
☐Pharmacy to provide anaphylactic kit per provider protocol.
☐Pharmacy to provide ancillary supplies and pump as needed for infusion.
6. ☐ Dispense as written ☐ Substitution Permitted
PHYSICIAN’S SIGNATURE (required): _______________________________________________________________ Date: _____________

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