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Soliris

Patient Demographics

Patient Demographics

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Required Documentation

Required Documentation

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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

Generalized Myasthenia Gravis (gMG) – or – Atypical Hemolytic Uremic Syndrome (aHUS)

Paroxysmal Nocturnal Hemoglobinuria (PNH)

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Adverse Reaction & Anaphylaxis Orders

Adverse Reaction & Anaphylaxis Orders

LINE USE/CARE ORDERS

LINE USE/CARE ORDERS

Provider Information

Provider Information

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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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