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Xolair

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Sex
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Allergies

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Therapy
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Ordering Provider

Ordering Provider

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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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Has patient had results of a positive skin test or in vitro reactivity to a perennial aeroallergen?
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For idiopathic urticaria: Has the patient remained symptomatic despite H1 antihistamine treatment?
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Primary Diagnosis

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Primary Medication Order

Primary Medication Order

If necessary, Suite Life will round dose up/down due to payor guidelines. *Dosing for patients 12 years old and greater.
Medication Order (please select ONE)
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First Dose
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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.

E-signature image
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Please enter a 10-digit phone number (numbers only).
Please enter a 10-digit phone number (numbers only).
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Please enter a 10-digit phone number (numbers only).