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SIMPONI ARIA

Patient First Name

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Patient Last Name

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Patient’s Phone Number

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Date of Birth

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Address

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Allergies

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City, State, Zip

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Weight

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lbs

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kg

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Patient’s Email

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REQUIRED DOCUMENTATION

REQUIRED DOCUMENTATION

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PRIMARY DIAGNOSIS

PRIMARY DIAGNOSIS

L40.50 Athropathic psoriasis, unspecified

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L40.52 Psoriatic arthritis mutilans

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M05.79 Rheumatoid arthritis with rheumatoid factor multiple sites without organ/system involvement

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M05.9 Rheumatoid arthritis with rheumatoid factor, unspecified

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M06.09 Rheumatoid arthritis without rheumatoid factor, multiple sites

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M06.89 Other specified rheumatoid arthritis, multiple sites

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M06.9 Rheumatoid arthritis, unspecified

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M45.0 Ankylosing spondylitis of multiple sites in spine

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Other:

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LAB ORDERS: PLEASE INCLUDE FREQUENCY

LAB ORDERS: PLEASE INCLUDE FREQUENCY

CBC w/ diff & ANC

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Count

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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

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Diphenhydramine 50mg PO

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Diphenhydramine 25mg IVP

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Diphenhydramine 50mg IVP

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Pepcid 20mg PO

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Pepcid 20mg IVP

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Certrizine 10mg PO

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Tylenol 650mg PO

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Solu-medrol 40mg IVP

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Solu-cortef mg IVP

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Other:

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PRIMARY MEDICATION ORDER

PRIMARY MEDICATION ORDER

Simponi ARIA 2mg/kg ( ______________mg) IV at week 0,4, and 8 weeks

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MG:

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Simponi ARIA ___ mg/kg ( ____mg) every _____ weeks.

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MG:

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Other:

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First Dose:

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Refill x months unless otherwise noted:

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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

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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

ADVERSE REACTION & ANAPHYLAXIS ORDERS

Administer acute infusion reaction and anaphylaxis medications per Suite Life Health’s protocol

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Other: Please fax other reaction orders if checking this box

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PROVIDER INFORMATION: PLEASE CHECK PREFERRED FORM OF COMMUNICATION

PROVIDER INFORMATION: PLEASE CHECK PREFERRED FORM OF COMMUNICATION

Provider Name:

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Office Contact:

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Address

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Phone:

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City, State, Zip

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Fax

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NPI AND License:

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Email:

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Date

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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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