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Leqembi

Patient First Name

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Patient Last Name

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Email

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Date of Birth

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Sex

Male

Female

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Diagnosis (please provide ICD10 code)

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Other

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Allergies

NKDA (No Known Drug Allergies)

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Allergies (please specify)

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Therapy

New Therapy Order

Continuation of Therapy

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Date of last dose

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Ordering Provider

Ordering Provider

Ordering Provider Name

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Provider NPI

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Phone

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Fax

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Practice Address

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City

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State

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Zip Code

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Pre-Medication

Pre-Medication

Select each pre-medication ordered below. Then use the Pre-Medication dosing details field to specify the dose (mg) and route for each medication selected.

Acetaminophen (route: PO)

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Cetirizine (route: PO)

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Diphenhydramine (route: PO or IVP)

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Solu-Medrol (route: PO or IVP)

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Solu-Cortef (route: PO or IVP)

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Pre-Medication dosing details (specify mg and route for each drug selected)

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Other pre-medication (specify)

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Required Documentation

Insurance Card

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H&P

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Demographics

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Medication List

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Tried/Failed Therapies

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Medicare Registry #

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MRI within 1 year

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CSF or PET Scan showing Amyloid Pathology (or plasma p-tau)

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Cognitive Assessment & Score (MOCA or MMSE)

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Most Recent Labs

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FAQ Score

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Primary and Secondary Diagnosis

Primary Diagnosis

Primary Diagnosis

Z00.6 Encounter for examination for normal comparison and control in clinical research program

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Secondary Diagnosis

Secondary Diagnosis

G30.0 Alzheimer’s disease with early onset

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G30.1 Alzheimer’s disease with late onset

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G30.9 Alzheimer’s disease, unspecified

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Other (please specify)

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Primary Medication Order

Primary Medication Order

If necessary, Suite Life will round dose up/down according to payor guidelines. *Referring provider is responsible for obtaining an MRI prior to the 3rd, 5th, and 14th infusions.

Leqembi 10mg/kg IV (calculated dose ____mg) every 2 weeks.

Other (please specify)

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First Dose

Y

N

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Line Use/Care Orders

Start PIV/ACCESS CVC — Flush device per Suite Life Health’s protocol (see suitelifehealth.com for detailed policy)

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Other Flush Orders (please fax other line care orders if checking this box)

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Adverse Reaction & Anaphylaxis Orders

Administer acute infusion and anaphylaxis medications per Suite Life Health’s protocol (see suitelifehealth.com for detailed policy)

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Other (please fax other reaction orders if checking this box)

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Choose an office:

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Ordering Provider Signature

Ordering Provider Signature

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By submitting your signature, the parties agree that this agreement may be electronically signed. The parties agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

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Provider

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Date

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Phone

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Fax

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Best Contact Person in Office

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Phone

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