1. No category

Oncology Enrollment Form
& INFUSION SERVICES
1332 N. Federal Hwy
Pompano Beach Florida 33062
Last Name
Phone:
Fax:
Infusion/Nursing Fax
First Name
Home Phone
(
)
Home Address
Today’s Date
Work Phone
(
)
City
Cell Phone
)
State
Zip
866-778-8255
800-432-6614
866-398-2988
Date Needed
Physician’s Name (please print)
Hospital / Clinic
(
Address
Shipping Address (If different from home address)
Phone Number
Social Security Number
Office Contact
Date of Birth
City
State
Zip
Fax Number
Statement of Medical Necessity________________________________________________________________________________________________
Primary Diagnosis ____________________ICD 9 Code_________ Pt HT__________ Pt Wt________ Allergies_______
ANC___________ H/H___________ Platelets____________
HCV RNA__________
Primary Ins: _________________
ID#________________________
RX card (please fax copy)_____________
ID#_________________
Secondary Ins.________________
ID#________________________
Medicare Supp Ins.______________ ID#________________________
Medications
□ Arimidex 1mg
PLEASE DELIVER TO
Sig____________________ Qty________
□ Nexavar 200mg
Sig____________________ Qty________
□ Etoposide (VP-16) 50mg
Sig____________________ Qty________
□ Fareston 60mg
Sig____________________ Qty________
□ Femara 2.5mg
Sig____________________ Qty________
□ Methotrexate 2.5mg
Sig____________________ Qty________
□ Tarceva
□25mg □100mg □150mg
Sig____________________ Qty________
□PT HOME OR
□ Kytril 1mg
Sig____________________ Qty________
□ Marinol □2.5mg □5mg □10mg
Sig____________________ Qty________
Injectable
□ MD OFFICE
Refill X _______
Refill X _______
□ Other___________________________________
Sig____________________ Qty________
Refill X _______
Refill X _______
Refill X _______
Refill X _______
Refill X _______
Refill X _______
Refill X _______
Antiemetics
□ Anzemet □50mg □100mg
Sig____________________ Qty________
Group#__________
Group#__________
Group#__________
Group#__________
□ Thalomid □50mg □100mg □200mg
Sig____________________ Qty________
Refill X _______
□ Xeloda
□150mg □500mg
Sig____________________ Qty________
Refill X _______
□ Arimidex 1mg
Sig____________________ Qty________
Refill X _______
□ Gleevec
□100mg □400mg
Sig____________________ Qty________
Refill X _______
□ Leucovorin □5mg □10mg □15mg □25mg
Sig____________________ Qty________
Refill X _______
□ Nolvadex □10mg □20mg
Sig____________________ Qty________
Refill X _______
□ Temodar □5mg □20mg □100mg□250mg
Sig____________________ Qty________
Refill X _______
Steroids
□ Oxandrin □2.5mg □10mg
Sig____________________ Qty________
Ins. Phone#_________________________
Ins. Phone#_________________________
Ins. Phone#_________________________
Ins. Phone#_________________________
Refill X _______
Refill X _______
□ Emend
□ 80mg □125mg
Sig____________________ Qty________
□ Zofran
□4mg □8mg
Sig____________________ Qty________
Refill X _______
Refill X _______
Misc/Infusion
Refill X _______
□_____________________________________________
Sig____________________ Qty________
Refill X _______
□ Procrit □Aranesp
□Neupogen □ Neulasta
□ Vial □ Singleject
Dose_______________________ Sig____________________ Qty________
Refill X _______
MD Signature____________________________
DEA ____________________UPIN ____________________State LIc#_________________