GASTROENTEROLOGY ENROLLMENT FORM

GASTROENTEROLOGY ENROLLMENT FORM
Form Name (For PDF Naming Only)
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:
Delivery 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:
TB/PPD test given/intended to be given before start? (If Yes, please upload all available lab results)

YesNo
Hepatitis B ruled out?

YesNo
If no, has treatment started?

YesNo
Prior Failed Medications:
PRESCRIPTION INFORMATION

Please select a medication first, then complete and required Dose, Directions, Quantity and Refills
Medication

Cimzia®Donnatal® 16.2 mg/5mL ElixirDonnatal® 16.2 mg tabletsEntyvio®Humira®Simponi®Stelara®Xifaxan® 200 mg tabletsXifaxan® 550 mg tabletsUceris® 9 mg tabletsUceris® 2 mg/dose foamLinzess®Amitiza® 24 mcg capsulesAmitiza® 8 mcg capsulesMovantik®Relistor®Trulance®
Cimzia® Dose

Prefilled syringe starter kit200 mg/mL prefilled syringe
Induction dose: 400 mg Sub-Q at weeks 0, 2, and 4.

Quantity: 1 starter kit (6 prefilled syringes)
Maintenance Dose:
400 mg Sub-Q every 4 weeks 200 mg Sub-Q every 4 weeks

Quantity:
1 unit (2 prefilled syringes)
Directions
Take blanks mL by mouth times daily (elixir).
Quantity

118 mL473 mL
Directions
Take blanks tablets by mouth times daily.
Quantity

90 tablets240 tabletsOther
Dose: 300 mg vial
Directions:
Take 300 mg infused IV at 0, 2 and 6 weeks, then every 8 weeks thereafter.
Quantity: blanks # of 300 mg vials
Humira Dose

80 mg pens CF40 mg pens CF40 my prefilled syringe CF
Induction dose: Adults and children greater then or equal to 88 lbs: 160 mg Sub-Q day 1, 80 mg day 15, 40 mg day 29 and every other week thereafter

Quantity: 1 starter (3 pens)
Induction dose: Adults and children greater then or equal to 88 lbs: 40 mg Sub-Q every other week

Quantity: 1 unit (2 pens or prefilled syringes - as selected)
Simponi® Dose

100 mg/mL SmartJect100 mg/mL prefilled syringe
Simponi® Directions

Induction Dose: 200 mg Sub-Q at week 0, 100 mg at week 2 and every 4 weeks thereafterMaintenance Dose: 100 mg Sub-Q every 4 weeks
Simponi® Quantity

Induction: 3 SmartJect autoinjectorsMaintenance: 1 SmartJect autoinjectorInduction: 3 prefilled syringesMaintenance: 1 prefilled syringe
Dose:
90 mg prefilled syringe

Induction Date:   Date

Maintenance Dose:
Inject 1 syringe Sub-Q every 8 weeks after induction

Quantity:
1 prefilled syringe
Directions: Take one tablet by mouth three times daily for three days - Travelers Diarrhea

Quantity: 9 tablets
Directions

Take one tablet by mouth twice daily with or without food (Hepatic Encephalopathy)Take one tablet by mouth othree times daily for 14 days (IBS-D)
Quantity

42 tablets60 tablets
Directions: Take one tablet by mouth once daily in the morning with or without food. Quantity:

30 tablets60 tablets
Directions: Insert and administer 1 metered dose twice daily for two weeks followed by 1 metered dose once daily. Quantity:

2 week supply6 week supply
Directions: Take one 24 mcg capsule twice daily (CIC & OIC)

Quantity: 60 capsules
Directions: Take one 8 mcg capsule twice daily (IBS-C)

Quantity: 60 capsules
Linzess Dose

72 mcg capsules154 mcg capsules290 mcg capsules
Directions: Take one capsule by mouth daily

Quantity: 30 capsules
Dose: 25 mg tablet

Directions: Take 1 tablet by mouth daily in the morning

Quantity: 90 capsules
Dose: 150 mg tablets

Directions: Take 3 tablets by mouth daily

Quantity: 90 capsules
Dose: 3 mg tablets

Directions: Take 1 tablet by mouth daily

Quantity: 30 capsules
Dose: blanks
Directions: blank
Quantity: blanks
Refills
Comments
PRESCRIBER SIGNATURE

Please indicate substitution preferences, 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
Prescriber Signature

Clear
Date

MonthDayYear
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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