Cabenuva Enrollment Form
Form will be automatically sent to Sunray Specialty Pharmacy for processing. Please send an electronic prescription along with this form to avoid delays.
Patient's Name
*
First Name
Last Name
Patient's Date of Birth
*
-
Month
-
Day
Year
Date
If patient has Medicare, please include last 4 numbers of patient's social security number so that insurance information can be searched:
Patient's Gender
*
Please Select
Male
Female
Non-Binary
Prefer Not To Disclose
Patient's Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Patient's Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Patient's Height
*
Patient's Weight
*
Allergies to Medications
*
Concomitant Medications
*
Prescriber
*
Is this an initiation dose or a maintenance dose?
*
Initiation Dose (Cabenuva 600/900 once monthly x 2 months)
Maintenance Dose (Cabenuva 600/900 every other month)
Monthly Maintenance Dose (Cabenuva 400/600 once monthly)
Would you like to prescribe an oral lead-in?
*
Yes - Vocabria 30 mg po qd x 30 + Edurant 25 mg po qd x 30
No
When would you like for the patient to start on the Cabenuva injection?
*
-
Month
-
Day
Year
Date
When is the patient due for their next injection?
*
-
Month
-
Day
Year
Date
Please upload HIV viral load or fax to (215)471-4001
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Submit
Should be Empty: