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Copyright © 2017 by Diplomat Pharmacy Inc. All rights reserved. Diplomat is a registered trademark of Diplomat Pharmacy Inc. 06052017

Intravenous Immune Globulin Patient Information Prescriber + Shipping Information Patient Name: ________________________________ DOB: _____________ Sex: Female Male SSN: ______________________________________ Language: ________________ Wt:______ kg lbs Ht:______ cm in Address: ______________________________________________________ Apt/Suite: ________ City:____________________ State:______ Zip:______ Phone:____________________ Alternate Phone:______________________ Caregiver name: _________________________ Relation: _______________ Local Pharmacy: _________________________ Phone: ________________

Prescriber Name:_______________________________________________ NPI: _______________________________________________________ Address: _____________________________________________________ Apt/Suite: _______ City:____________________ State:______ Zip:______ Contact: ______________________________________________________ Phone: ________________________ Alternate: ______________________ Fax: _________________________________________________________ Email address: ________________________________________________ If shipping to presciber: First Fill Always Never

Insurance Information (Please fax a copy of front and back of the insurance cards) 1˚ Insurance Plan: _____________________ Plan ID # ___________________ Policy Holder: ___________________________ Relation: ______________ 2˚ Insurance Plan: _____________________ Plan ID # ___________________ Policy Holder: ___________________________ Relation: ______________

Clinical Information (Please fax all pertinent clinical and lab information) Diagnosis Code: _________________________________________________________________________________________________________ Date of Diagnosis: _______________________________________________

IgA deficiency: Yes No IgA level _________ mg/dL Date:___________

IgG trough:______mg/dL Date:______ Diabetic: Yes No

Access: Peripheral PICC Implant Port Broviac®/Hickman®

Has patient received immune globulin previously? Yes No If yes, product information: _______________________________________ Date of last infusion: ____________ Date of next infusion: ______________

Comorbidities: __________________________________________________________________________________________________________________Concomitant Medications: _________________________________________________________________________________________________________Allergies: NKDA Other: _____________________________________________________________________________________________________

Prescription

Immune Globulin Products

Carimune® NF Flebogamma® 5% Flebogamma® 10% Gammaked® 10%

Gammagard® Liquid10% Gammaplex® 5% Gammagard® S/D

Gamunex-C® 10% Octagam® 5% Octagam® 10% Privigen® 10%

IVIG (Pharmacy to determine)

Therapy Regimen

Dose: ____________________ g/kg Total dose: ____________________ grams Daily for __________________ days every _________________________ weeks Quantity to Dispense: _________________ doses Refills: _____________________ Administration Rate: Per manufacture guidelines, as tolerated ____________________________________________

Pre-Medications and Pre-Protocol

Diphenhydramine _____mg 30 min before infusion PO IVP

Acetaminophen _____mg 30 min before infusion PO Other: _________________________________________ Other: _________________________________________

Hydration Infuse _____ mL _______________ solution Prior to Following

Solu-Cortef® ___________ mg slow IVP Solu-Medrol® ___________ mg slow IVP

Pre Halfway Upon completion

Flushing Protocol Sodium Chloride 0.9% 5-10 mL pre and post medications Heparin ________Units/mL _________mL as needed

Anaphylaxis Orders and Medications

Orders: 2. Call 911 and prescribing physician3. Administer medications below as per protocol

Diphenhydramine 50 mg/mL

Quantity: 1 x 50 mg vial

Epinephrine 1 mg/mL

Quantity: 2 vials

Sodium Chloride 0.9% Use as directed per protocol Quantity: 1 x 500 mL Bag Pump and Ancillary Supplies

Skilled Nursing Visits As needed for IV access, administration and appropriate clinical monitoring.Administration procedures to be followed per pharmacy protocol.

Per state-specific law, prescriptions will be dispensed as generic, if applicable, unless notated otherwise: ______________________________

Prescriber’s Signature:______________________________________________________________________ Date: _________________ I authorize Diplomat Pharmacy, Inc. and its representatives to act as an agent to initiate and execute the insurance prior authorization process for this prescription and any future

fills of the same prescription for the patient listed above. I understand that I can revoke this designation at any time by providing written notice to Diplomat Pharmacy, Inc.

The quantity and refills for pre-treatment and flushing protocol medications will match the immune globulin administration requirements.

Administer 12.5 mg/0.25 mL (weight <15 kg) by slow IV push or IM Administer 25 mg/0.5 mL (weight 15-30 kg) by slow IV push or IM Administer 50 mg/mL (weight >30 kg) by slow IV push or IM

Administer ____ mg (0.01 mg/kg or 0.01mL/kg) (weight <15 kg) IM Administer 0.15 mg/0.15 mL (weight 15-30 kg) IM Administer 0.3 mg/0.3mL (weight >30 kg) IM

1. Stop infusion

Pump and supplies as needed for administration and appropriate disposal of infusion materials.

Refills

Check here if you would like Adjusted Body Weight used for dosing (if patient > 100kg)

Gammaplex® 10%

Stamp signature not allowed, physician signature required.