Case Manager/Provider New Infusion Referral Please complete as much information below "*" indicates required fields Ordering Provider* Ordering Provider NPI Person Submitting Request* Callback Phone Number*Drug*ACYCLOVIR 1 GM-20 ML VL 10X20 MLAMIKACIN SUL 500 MG-2 ML SDV 10X2 MLAMPICILLIN 2 GM VL 10AVELOX IV 400 MG FLX BAG 12X250 MLAZACTAM 1 GM SDV 10X15 MLAZITHROMYCIN INJ 500MG VL 10-VLAZTREONAM 2 GM VL 10BUMETANIDE 0.25 MG-ML MDV 10X10 MLCATHFLO ACTIV 2 MG VL 2 MLCEFAZOLIN 1 GM VL 25CEFAZOLIN 1 GM VL 25CEFEPIME 1 GM VL 10CEFTRIAXONE 1 GM VL 10CIPROFLOXACIN 400 MG BAG 24X200 MLCLEOCIN 300 MG VL 25X2 MLCLINDAMYCIN PHOS 300 MG-2 ML SDV 25X2 MLCLINIMIX 5-15% BAG 4X2000 MLCOLISTIMETHATE 150 MG SDVCUBICIN 500 MG VL 10 MLDAPTOMYCIN (LATEX FREE) 500 MG-10ML SDVDEXAMETHASONE 4 MG-ML SDV 25X1 MLDEXTROSE-LAC RNG 5% BAG 12X1000 MLDEXTROSE-NACL 5-0.45% BAG 12X1000 MLDEXTROSE-WATER 5% BAG 12X1000 ML LCDIAZEPAM 5 MG-ML MDV 10X10 MLDIPHENHYDRAMINE HCL 50 MG-ML VL 25X1 MLDOBUTAMINEDOXYCYCLINE HYCLATE 100 MG VL 10ENOXAPARIN SOD 300 MG-3 ML MDV 3 MLENTYVIO 300MG 20ML SDV EA ASDEPINEPHRINE 1 MG-ML AMP 25X1 MLEPOGEN S4 4M UN/ML VL 10X1 MLFAMOTIDINE 200 MG-20 ML MDV 10X20 MLFENTANYL CIT PF 50 MCG/ML SDV 25X2 MLFERAHEME 510 MG VL 17 MLFLUCONAZOLE-NACL 400 MG BAG 10X200 MLFUROSEMIDE 40 MG-4 ML VL 25X4 MLGAMMAGARD ASD 30 GM VL 300 MLGENTAMICIN 80 MG-2 ML MDV 25X2 MLGRANISETRON HCL 1 MG-ML SDV 10X1 MLHALOPERIDOL LAC 5 MG-ML SDV 25X1 MLHEPARIN LF 30 UN-3 ML SYG 30X3 MLHYDROMORPHONE HCL 10 MG/ML AMP 10X5 MLINFLECTRAINFUVITE ADULT MULTI VIT VL 5X2X5 MLINFUVITE PED MULT VIT VL 5X5 MLINJECTAFER 750 MG VL 15 MLINTRALIPID 20% INJ 6X1000MLINVANZ 1 GM VL 10KCL-DEX-NACL 20MEQ-5-0.45% BAG 14X1000MLKETOROLAC TRO 30 MG-ML SDV 25X1 MLLACTATED RINGERS VFLX BAG 14X1000 MLLEVOFLOXACIN-D5W 500 MG IVPB 24X100 MLLORAZEPAM 2 MG-ML SDV 25X1 MLLOVENOX 300 MG VL 3 MLMEROPENEM 1 GM VL 10METHADONE HCL 200 MG/20 ML MDV 20 MLMETRONIDAZOLE 500 MG IVPB 24X100 MLMIDAZOLAM HCL 10 MG-2 ML VL 10X2 MLMILRINONE 50 MG-50 ML SDV 50 MLMOXIFLOXACIN INJ 400MG BAG 12X250MLMULTITRACE-5 CONCENTRATE MDV 25X10 MLMYCAMINE 100 MG VL 5 MLNAFCILLIN 2 G VL 10NEUPOGEN 300 MCG/ML VL 10X1 MLNucalaNULOJIX 250 MG VL 1OCTREOTIDE 0.2 MG/ML VL 5 MLONDANSETRON 2 MG-ML SDV 25X2 MLOther IVIG Products as availableOXACILLIN 2 GM VL 10PENICILLIN G POTASS 20 MMU VLPHENOBARB 65 MG VL 25X1 MLPIPERACILLIN-TAZOBACT 3.375GM VL 10X30MLPRIVIGEN ASD 10 GM VL 100 MLPROMETHAZINE 25 MG-ML VL 25X1 MLPROTONIX IV 40 MG VL 25RADICAVAREMICADE 100 MG VLSMOFLIPID 20% INJ 10X250 MLSODIUM CHLORIDE 0.45% INJ BAG 14X1000 MLSOLU MEDROL 125 MG AOV 25X2 MLSULFAMETH/TRI 80/ 16MG VL 10X10 MLTEFLARO 400 MG VL 10X20 MLTOBRAMYCIN 1200 MG MDV 30 MLTPN / PN / Parenteral NutritionTrace ElementsTRAVASOL 10 % SOL 6X2000 MLTROPHAMINE 10 % SOL 6X500 MLVANCOMYCIN 1 GM VL 10VENOFER 20 MG/ML SDV 10X5 MLVIBATIV 750 MG SDV 1ZYVOX 600MG/300ML INJ 10Patient InformationPatient Name:* Date of Birth* MM slash DD slash YYYY Address:* City:* State:* Zip:* Patient Phone*Alternate Phone:Insurance* Upload additional documentationMax. file size: 50 MB.CAPTCHA Printable Infusion Order Form Printable Infusion Suite Order Form
