ONCOLOGY PRESCRIPTION REFERRAL FORM

ONCOLOGY PRESCRIPTION REFERRAL FORM Today's Date
314 E 204th St., Bronx, NY 10467 November 23, 2024
Phone: 718-882-5614   Fax: 718-882-6365
Patient Name Date Of Birth Weight Gender
Street Address Apartment # City State Zip
Daytime Telephone Evening Telephone Cellphone Email Address
Ship To Patient At Date Needed
    OR Patient will pick up at  
ICD-10 CODE Diagnosis Allergies BSA m2
Biopsy Results Patient Currently on Therapy Date of Next Blood Work
   
INSURANCE INFORMATION Please fax copy of insurance card (front & back)
Prescriber's Name Office Contact
Street Address Suite # City State Zip
Telephone Fax Number Email Address
License # NPI # UPIN # DEA #

 

Afinitor Gleevec Tamoxifen Xtandi
Avastin Herceptin Tarceva Yervoy
Arimidex Hycamtin Tasigna Zelboraf
Aromasin Nexavar Tykerb 250mg Zoladex
Docetaxel Promacta Temodar Zolinza
Erbitux Rituxan Thalimid* Zometa
Eloxatin Sutent Velcade Zytiga
Etoposide Sprycel Votrient 200mg Thalimid
*Authorization #
Erivedge Stivarga Xclair
Folotyn Sylatron Xeloda
Strength
SIG
QTY Refills
XGEVA Strength: 120 mg/1.7 mL (70 mg/mL) single-use vial
QTY Refills
120 mg SQ every 4 weeks in the upper arm, upper thigh, or abdomen 120 mg SQ every 4 weeks in the upper arm, upper thigh, or abdomen
Additional 120 mg doses on days 8 and 15 of the first month of therapy
Antiemetics Chemo-induced
Compazine Emend Zofran Sancuso Transdermal Patch Other
Dosage QTY Refills
Neupogen
300 mcg SQ 480 mcg SQ Other
QTY Refills
Daily x days Every week BIW TIW
Procrit 40,000 units SQ Weekly Other
QTY Refills
Aranesp Caphosol Nplate Zofran
Neumega 5mg vial Kytrel Neulasta
Arixtra Lovenox Promacta
Dosage SIG
QTY Refills

Prescriber's SignatureDate: November 23, 2024

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