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Actemra

Patient Demographics


Patient Demographics

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Allergies
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Required Documentation


Required Documentation

Please include the following information: Insurance Card, H&P, Patient Demographics, Baseline LFTs and Lipid Panel, and Medication List
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Primary Diagnosis


Primary Diagnosis

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Lab Orders: Please Include Frequency


Lab Orders: Please Include Frequency

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Pre-medications (15 - 20 Mins Before Infusion)


Pre-medications (15 - 20 Mins Before Infusion)

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Primary Medication Order


Primary Medication Order

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Line Use / Care Orders


Line Use / Care Orders

Adverse Reaction & Anaphylaxis Orders


Adverse Reaction & Anaphylaxis Orders

Provider Information: Please Check Preferred Form of Communication


Provider Information: Please Check Preferred Form of Communication

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Please sign your name in the area below

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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