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Refer A Patient
FIND A LOCATION
REFER A PATIENT
Conditions We Treat
How We Work
Referral Process
For Patients
What To Expect
FAQs
Blog
Contact Us
Refer A Patient
Krystexxa Order Form
Δ
Select Location
(Required)
Charleston
Bluffton
Knoxville
Sandy Springs
First Name
(Required)
Last Name
(Required)
Email Address
(Required)
New Start | Maintenance
(Required)
New Start
Maintenance
Last Dose Given
(Required)
Referring Office
(Required)
Contact Name
(Required)
Date
(Required)
MM slash DD slash YYYY
Direct Phone for Contact
(Required)
Fax
(Required)
Patient Name
(Required)
Date of Birth
(Required)
MM slash DD slash YYYY
Allergies
(Required)
Allergies
NKDA
Allergies
(Required)
Height
(Required)
Weight
(Required)
IS THE PATIENT G6PD DEFICIENT?
(Required)
Yes
No
Has the patient been initiated on immunomodulatioon with Methotrexate or Cellcept?
(Required)
Yes
No
Indication
(Required)
M1A.09X1 Chronic gout, unspecified, with tophus (tophi)
M 1A.____
Other
M 1A.____
(Required)
Indication (Other)
Dosage Orders
(Required)
8mg IV every 2 weeks
Other
Dosage Orders (Other)
(Required)
Premedication Orders (not required by PI)
Acetaminophen
Diphenhydramine
Methylpredisolone
Other
Premedication Orders (Other)
Acetaminophen
1000mg PO
500mg PO
30min prior to infusion
Diphenhydramine
25mg PO
50mg PO
25mg IVP
30min prior to infusion
Methylpredisolone
62.5mg IVP
125mg IVP
Other
30min prior to infusion
Solu-Medrol (Other)
Prescriber Name
(Required)
Title
(Required)
NPI
(Required)
DEA
(Required)
Date of Order
(Required)
MM slash DD slash YYYY
Referrals will not be processed untill we receive ALL the following:
(Required)
Face Sheet / Patent Demographics
Insurance card(s) – copy of front & back
Last 2 clinic notes pertaining to referring diagnosis (include ALL past & failed therapy outcomes)
Most Recent Labs (within last 4-8 weeks) – Required:
(Required)
CBC
CMP
G6PD
Serum Uric Acid (within 1 month of initiation, within 48 hours for ongoing treatment
Other
Documentation of initiation of methotrexate and folic acid
Most Recent Labs (OTHER)
CAUTION: Referring provider has verified patient's G6PD status
(Required)
Demographic and insurance information
(Required)
Max. file size: 5 MB.
Necessary lab results as needed by drug protocol
(Required)
Max. file size: 5 MB.
Office notes that support the medical necessity for infusion therapy
Office notes that support the medical necessity for infusion therapy
(Required)
Max. file size: 5 MB.
* Required
Office notes that support the medical necessity for infusion therapy
(Required)
Contact information for referring provider
Referrer Provide Name
(Required)
Referrer Practice Name
(Required)
Referrer Address
(Required)
Referrer Phone
(Required)
Referrer Fax
(Required)
Nursing Oders
Start PIV/Access CVC (CXR confirmation required)
Flush device per Ascend flushing procedures
Provide nursing care per Ascend Infusion Nursing policies and procedures
Provide acute care for infusion reactions following protocol orders which can be located on our website
