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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.
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Required Documentation
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Primary Diagnosis
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Clinical Monitoring
Clinical Monitoring
Hearing test, before, during, and after treatment – to be maintained and monitored by prescriber.
Urine pregnancy test before each dose (if of childbearing age) – to be maintained and monitored at the infusion center.
Finger stick blood glucose before each dose – to be maintained and monitored at the infusion center.
Primary Medication Order
Primary Medication Order
If necessary, Suite Life will round dose up/down according to payor guidelines. **Patients with pre-existing diabetes should be under appropriate glycemic control before receiving Tepezza.
Tepezza 10 mg/kg, then 3 weeks following 20 mg/kg IV for seven additional treatments. First two doses over 90 mins, subsequent doses over 60 mins.
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Line Use/Care Orders
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Adverse Reaction & Anaphylaxis Orders
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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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