DERMATOLOGY ENROLLMENT FORM

DERMATOLOGY ENROLLMENT FORM
E-Prescribing is encouraged for quicker turnaround time for our patients.

See our e-prescribe information below!
PATIENT INFORMATION
Patient Name:*
Date of Birth:*

MonthDayYear
Date
Gender:

MaleFemalePrefer Not to SayOther
Address

Address

Street Address Line 2

CityState

Zip
Phone Number:*
Alt. Phone Number:
Allergies:*
If no known drug allergies, please put N/A
Language:
Height:
Weight:
SSN:
Product Shipping Options:

Patient’s HomePrescriber OfficeAlternative Address
Alt. Address

Street Address

Street Address Line 2

CityState

Zip Code
PRESCRIBER INFORMATION
Prescriber :*
Provider PIN:*
Please provide your verification PIN. For those new to our pharmacy, please put 11111 and we'll reach out to you to set up a PIN.
NPI:*
DEA:
Phone Number:*
Fax Number:
Practice Name:
Office Contact:
Practice Address:

Street Address

Street Address Line 2

CityState

Zip Code
CLINICAL INFORMATION
Please upload all relevant and available chart notes including lab results:

Cancelof
Diagnosis /ICD-10:
Does the patient have a latex allergy?

YesNo
IGA Score
TB/PPD test given?

YesNo
% BSA affected:

PalmsSolesHeadNeckGenitalia
Is Hepatitis B ruled out?

YesNo
If no, has treatment started?

YesNo
Prior Failed Medication(s):

EnbrelHumiraMethotrexatePUVASimponiStelaraTopicalOther
For Topical, Please list:
PRESCRIPTION INFORMATION
Medication:

CimziaCosentyxDupixentEnbrelHumiraIlumyaOtezlaRemicadeSimponi® (psoriatic arthritis)Stelara®Taltz®Tremfya™Siliq™Xeljanz®Xeljanz® XROther:
Cimzia Dose:

200 mg prefilled syrings
Cimzia Directions:

Starter dose: inject 400 mg Sub -Q at weeks 0, 2, and 4Maintenance dose: inject 400 mg Sub-Q every 4 weeksMaintenance dose: inject 200 mg Sub-Q every 2 weeks
Cimiza Quantity:

1 Starter pack
Cimiza Quantity:

2 syringes
Cosentyx Dose:

150 mg/mL Sensoready® pen150 mg/mL prefilled syringe
Cosentyx Directions with a Loading Dose:

Inject 150 mg Sub-Q on week 0, 1, 2, 3 and 4 then inject 150 mg Sub-Q once every 4 weeks (FOR PSORIATIC ARTHRITIS)
Cosentyx Directions without a Loading Dose:

Inject 150 mg Sub-Q once every 4 weeks (FOR PSORIATIC ARTHRITIS)Inject 300 mg Sub-Q on week 0, 1, 2, 3 and 4 then inject 300 mg Sub-Q once every 4 weeksInject 300 mg Sub-Q every 4 weeks (FOR PLAQUE PSORIASIS)
Cosentyx Quantity:

1 pen/syringe
Cosentyx Quantity:

3 pens/syrings
Dupixent Dose:

300 mg/2 mL solution in a single-dose pre-filled syringe with needle shield
Dupixent Directions:

Starter dose: inject 600 mg (2 syringes in 2 different injection sites) Sub-Q day 1Maintenance dose: inject 300 mg Sub-Q every other week (starting 14 days after day 1)
Dupixent Quantity:

2 syringes
Enbrel Dose:

50 mg/mL prefilled syringe50 mg/mL SureClick™ autoinjector
Enbrel Directions:

Starter dose: inject 50 mg Sub-Q twice a week (72-96 hours apart for 3 months)Maintenance dose: inject 50 mg Sub-Q once a week
Enbrel Starter Quantity:

8 pens/syringes
Enbrel Maintenance Quantity:

4 pens/syrings
Humira Dose:

40 mg/mL prefilled pen40 mg/mL prefilled syringe
Humira Directions:

Starter dose: inject 80 mg Sub-Q day 1Maintenance dose: inject 40 mg Sub-Q every other week (starting 1 week after initial dose)
For Hidradenitis Suppurativa only:

Starter dose: inject 160 mg Sub -Q day 1 , then 80 mg 14 days after, then 40 mg on day 29Maintenance dose: inject 40 mg Sub-Q every week (starting 1 week after day 29 dose)
Humira Quantity:

Starter pack2 pens/syringes
Hidradenitis Suppurativa Qty:

Starter pack4 pens/syringes
Ilumya Dose:

100 mg/mL prefilled syrings
Ilumya Directions:

Starter Dose: inject 100 mg Sub-Q at week 0 and week 4Maintenance dose: inject 100 mg Sub -Q every 12 weeks
Ilumya Quantity:

1 prefilled syringe
Otezla Dose:

Starter PackBridge Pack30 mg tablet
Otezla Directions:

Titrate dose days 1 through 5 and as directed thereafter
Otezla Qty:

1 pack
Otezla Directions:

Take 30 mg by mouth once dailyTake 30 mg by mouth twice daily
Otezla Qty:

28 Tabs
Otezla Directions:
Take 30 mg by mouth twice daily. Titration Date:Date
Otezla Qty:

60 Tabs
Remicade

Dose: 100 mg vial

Directions: Infuse IV at 5 mg/kg (Dose = mg) at week 0, week 2, week 6 and every 8 weeks thereafter. ( For Plaque psoriasis and Psoriatic arthritis).

Quantity: blank # of 100 mg vials.
Simponi Dose:

50 mg/0.5mL SmartJect autoinjector50 mg/0.5mL prefilled syringe
Simponi Directions: Inject 50 mg Sub-Q once a month

Qty: 1 pen/syringe
Stelara Dose:

50 mg/0.5mL SmartJect autoinjector50 mg/0.5mL prefilled syringe
Stelara Directions:

Inject contents of 1 syringe Sub-Q on day 0, 4 weeks later, and then every 12 weeksInject 1 syringe Sub-Q every 12 weeks
Stelara Qty:

1 syringe
Taltz Dose:

80 mg autoinjector80 mg prefilled syringe
Taltz Directions:

Starter dose: inject 160 mg Sub-Q at week 0, then begin induction dose 2 weeks laterInduction dose: inject 80 mg Sub-Q every two weeks (weeks 4 – 10)Final Induction dose: inject 80 mg Sub-Q at week 12Maintenance dose: inject 80 mg Sub-Q every 4 weeks (thereafter)
Taltz Qty (Starter dose):

3 pens/syringes
Taltz Qty (Induction dose):

2 pens/syringes
Taltz Qty (final induction / maintenance):

1 pen/syringe
Tremfya Dose:

100 mg/mL prefilled syringe
Tremfya Qty:

1 syringe
Tremfya Directions:

Starter dose: inject 100 mg Sub-Q at weeks 0, 4 and then every 8 weeks afterMaintenance dose: inject 100mg Sub-Q every 8 weeks
Siliq Dose:

210 mg/1.5mL prefilled syringe
Siliq Qty:

2 pens
Siliq Directions:

Starter dose: inject 210 mg Sub-Q at weeks 0, 1 and 2 and then every 2 weeks afterMaintenance dose: inject 210mg Sub-Q every 2 weeks
Xeljanz Rx Information

Dose:

5 mg Tablets

Directions:

Take 1 tablet by mouth twice daily for psoriatic arthritis

Qty:

60 tabs
Xeljanz XR Rx Information

Dose:

11 mg Tablets

Directions:

Take 1 tablet by mouth daily with or without food for psoriatic arthritis

Qty:

30 tabs
Dose: please provide dose

Directions: blank

Qty:
Refills:
PRESCRIBER SIGNATURE

PLEASE SIGN AND DATE BELOW
Prescriber Authorization: I authorize this pharmacy and its representatives to act as my authorized agent to secure coverage and initiate the insurance prior authorization process for my patient(s), to sign any necessary forms on my behalf as my authorized agent, including the receipt of any required prior authorization forms, the receipt and submission of patient lab values and other patient data including pursuing available copay and financial assistance on behalf of my patients. If this pharmacy determines that it is unable to fulfill this prescription, I further authorize this pharmacy to forward this information and any related materials related to coverage of the product to another pharmacy of the patient’s choice or in the patient’s insurer’s provider network.
Substitution Preferences:

Product substitution permittedDispense as WrittenTherapeutic substitution permitted
Signature

Clear
Date

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Date
CONFIDENTIALITY NOTICE: This form and its contents may contain private and confidential information that is intended for the individual or entity to which it is addressed. Any transmission of this form may contain information that is exempt from disclosure under laws including but not limited to the Health Insurance Portability and Accountability Act (HIPAA Unless explicitly stated, you are strictly prohibited from disseminating, copying or distributing any material contained within. Violators will be prosecuted to the fullest extent of the law. If you received this communication in error, please notify us immediately and destroy this form and its contents.
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