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Leqembi

Patient Demographics

Patient Demographics

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Required Documentation

Required Documentation

Primary Diagnosis

Primary Diagnosis

Primary Diagnosis
Secondary 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

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

Supportive Therapies

Immunomodulators to be prescribed & managed by:
PRN Gout Flare Treatment:

Line Use / Care Orders

Line Use / Care Orders

Adverse Reaction & Anaphylaxis Orders

Adverse Reaction & Anaphylaxis Orders

Provider Information

Provider Information

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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.

E-signature image
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