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Nulojix

Patient Demographics

Patient Demographics

Patient First Name

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Patient Last Name

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Phone:

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Date of Birth

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Address:

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Allergies

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City

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State:

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Zip:

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Weight (specify in lbs or in kg)

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Email

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Required Documentation

Required Documentation

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Click to upload files

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Primary Diagnosis

Primary Diagnosis

Z94.0 Kidney transplant status

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Z48.22 Encounter for aftercare following kidney transplant

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Other

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Orders: Please Include Frequency

Orders: Please Include Frequency

CBC w/ diff & ANC:

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LFT's at month 2 then every 3 months after

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Other:

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Pre-Medications (15-20 Mins Before Infusion)

Pre-Medications (15-20 Mins Before Infusion)

Diphenhydramine 25mg PO or IVP & 50mg PO or IVP

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Cetrizine 10mg PO

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Pepcid 20mg PO or IVP

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Solu-Medrol 40mg IVP

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Solu-Cortef 100mg IVP

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Tylenol 650mg PO

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Other:

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Primary Medication Order

Primary Medication Order

Referring provider is responsible for obtaining an MRI prior to the 5th, 7th, and 14th infusions infuse over 1 hour

Induction : Nulojix 10mg/kg IV on days 1, 4, 14, then monthly x3 doses infuse over 30 mins

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Maintenance Nulojix 5mg/kg IV monthly Infuse over 30mins

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"Calculated dose will become fixed dose throughout treatment based on actual body weight at time of transplant unless otherwise specified"

Patient weight at the time of transplant

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Dose:

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Other:

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First Dose:

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Refill x12 months unless otherwise noted:

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Notes:

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Line Use / Care Orders

Line Use / Care Orders

Start PIV/ACCESS CVC

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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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Supportive Therapies

Supportive Therapies

Immunomodulators to be prescribed & managed by:

Infusion Clinic

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Referring Provider

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PRN Gout Flare Treatment:

Colchine 0.6mg PO BID PRN gout flares

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Medrol Dosepak PRN gout flares

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Naproxen 500mg PO BID PRN gout flares

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Adverse Reaction & Anaphylaxis Orders

Adverse Reaction & Anaphylaxis Orders

Administer acute infusion reaction 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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Provider Information

Provider Information

Provider Name

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Office Contact:

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Address:

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Phone:

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City:

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State:

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Zip:

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Fax:

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NPI and License

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Email:

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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.

E-signature image

Date:

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