Submit an order form by fax or email


Download and print therapy-specific order forms below. You can fax or email the completed form directly to your Local Infusion center along with supporting clinicals.

Fax numbers for each location can be found below and on our Locations page.

Fax numbers by state
  • Connecticut: 203-433-0621
  • Florida: 904-877-9270
  • Georgia: 770-502-6797
  • Massachusetts: 413-296-8482
  • Maryland: 240-224-8607
  • Maine: 207-407-7272
  • North Carolina: 919-984-8698
  • New Hampshire: 603-217-5371
  • New Jersey: 201-581-4521
  • New York: 631-250-6020
  • Ohio: 937-871-4594
  • Pennsylvania: 610-273-5998
  • South Carolina: 864-973-6279
  • Texas: 469-242-9788
  • Virginia: 703-202-0499

Hate faxing?  You can also submit a digital order form and eSign. We’ll send you a copy for your records. 

Actemra & Biosimilars

E-Order (quickest option)

Download Actemra order form here.

Required clinicals:

  • Negative TB screen
  • CBC with differential
  • Liver function test
  • Demographics
  • Labs & Tests Supporting Diagnoses
  • Office/Progress Notes
Alpha 1-Proteinase Inhibitor (Human)

E-Order (quickest option)

Download Alpha 1-Proteinase Inhibitor (Human) order form here.

Required clinicals: 

  • Demographics
  • Labs & Tests Supporting Diagnoses 
  • Office/Progress Notes
Amvuttra

E-Order (quickest option)

Download Amvuttra order form here.

Required clinicals:

  • Demographics
  • Labs & Tests Supporting Diagnoses 
  • Office/Progress Notes
Apretude

E-Order (quickest option)

Download Apretude order form here.

Required clinicals:

  • Individuals must have a negative HIV-1 test prior to initiating (with or without an oral lead-in with oral cabotegravir) for HIV-1 PrEP
Avastin

E-Order (quickest option)

Download Avastin order form here.

Required clinicals:

  • Demographics
  • Labs & Tests Supporting Diagnoses 
  • Office/Progress Notes
Benlysta

E-Order (quickest option)

Download Benlysta order form here. 

Required clinicals:

  • Demographics
  • Labs & Tests Supporting Diagnoses 
  • Office/Progress Notes
Briumvi

E-Order (quickest option)

Download Briumvi order form here.

Required clinicals: 

  • Demographics
  • Labs & Tests Supporting Diagnoses 
  • Office/Progress Notes
  • Negative Hep B – HBsAg (Hepatitis B surface antigen) and Anti-HBc (Hepatitis B core antibody) 
  • Baseline liver function tests (LFTs) (ALT, AST, bilirubin, alkaline phosphatase) within 6 months for new starts
  • Serum immunoglobulins
Cabenuva

E-Order (quickest option)

Download Cabenuva order form here.

Required clinicals:

  • Demographics
  • Labs & Tests Supporting Diagnoses 
  • Office/Progress Notes
Cimzia

E-Order (quickest option)

Download Cimzia order form here.

Required clinicals: 

  • Demographics
  • Labs & Tests Supporting Diagnoses 
  • Office/Progress Notes
  • Negative TB screen
  • HBsAg (Hepatitis B surface antigen) 
Cinqair

E-Order (quickest option)

Download Cinqair order form here.

Required clinicals: 

  • Demographics
  • Labs & Tests Supporting Diagnoses
  • Office/Progress Notes
Cosentyx IV

E-Order (quickest option)

Download Cosentyx IV form here

Required clinicals: 

  • Negative TB test
  • Demographics
  • Labs & Tests Supporting Diagnoses 
  • Office/Progress Notes
Elfabrio

E-Order (quickest option)

Download Elfabrio order form here.

Required clinicals: 

  • Demographics
  • Labs & Tests Supporting Diagnoses
  • Office/Progress Notes
Enjaymo

E-Order (quickest option)

Download Enjaymo order form here.

Required clinicals: 

  • Demographics
  • Labs & Tests Supporting Diagnoses
  • Office/Progress Notes
Entyvio

E-Order (quickest option)

Download Entyvio order form here.

Required clinicals: 

  • Demographics
  • Labs & Tests Supporting Diagnoses 
  • Office/Progress Notes
Evenity

E-Order (quickest option)

Download Evenity order form here.

Required clinicals: 

  • Normal calcium within 6 months of referral 
  • Demographics
  • Labs & Tests Supporting Diagnoses 
  • Office/Progress Notes
Evkeeza

E-Order (quickest option)

Download Evkeeza order form here.

Required clinicals:

  • Demographics
  • Labs & Tests Supporting Diagnoses 
  • Office/Progress Notes
Exdensur

E-Order (quickest option)

Download Exdensur order form here.

Required clinicals:

  • Demographics
  • Labs & Tests Supporting Diagnoses 
  • Office/Progress Notes
Fabrazyme

E-Order (quickest option)

Download Fabrazyme order form here.

Required clinicals:

  • Demographics
  • Labs & Tests Supporting Diagnoses 
  • Office/Progress Notes
Fasenra

E-Order (quickest option)

Download Fasenra order form here.

Required clinicals:

  • Demographics
  • Labs & Tests Supporting Diagnoses 
  • Office/Progress Notes
Faslodex

E-Order (quickest option)

Download Faslodex order form here.

Required clinicals:

  • Demographics
  • Labs & Tests Supporting Diagnoses
  • Office/Progress Notes
  • Confirmed Hormone Receptor–Positive (HR+) Disease
Gazyva

E-Order (quickest option)

Download Gazyva order form here.

Required clinicals:

  • Demographics
  • Labs & Tests Supporting Diagnoses 
  • Office/Progress Notes
  • Negative Hep B – HBsAg (Hepatitis B surface antigen) and Anti-HBc (Hepatitis B core antibody)
Givlaari

E-Order (quickest option)

Download Givlaari order form here.

Required clinicals: 

  • Liver function tests prior to starting treatment (within 6 months of referral)
  • Demographics
  • Labs & Tests Supporting Diagnoses 
  • Office/Progress Notes
Herceptin

E-Order (quickest option)

Download Herceptin order form here.

Required clinicals: 

  • Demographics
  • Labs & Tests Supporting Diagnoses
  • Office/Progress Notes
  • Confirmed HER2-Positive Status
HyQvia

E-Order (quickest option)

Download Hyqvia order form here.

Required clinicals:

  • Demographics
  • Labs & Tests Supporting Diagnoses 
  • Office/Progress Notes
Ilaris

E-Order (quickest option)

Download Ilaris order form here.

Required clinicals: 

  • Negative TB
  • Demographics
  • Labs & Tests Supporting Diagnoses 
  • Office/Progress Notes
Ilumya

E-Order (quickest option)

Download Ilumya order form here.

Required clinicals: 

  • Negative TB
  • Demographics
  • Labs & Tests Supporting Diagnoses 
  • Office/Progress Notes
Imaavy

E-Order (quickest option)

Download Imaavy order form here.

Required clinicals: 

  • Demographics
  • Labs & Tests Supporting Diagnoses
  • Office/Progress Notes
Isembyld

E-Order (quickest option)

Download Isembyld order form here.

Required clinicals: 

  • Demographics
  • Labs & Tests Supporting Diagnoses
  • Office/Progress Notes
IVIG

E-Order (quickest option)

Download IVIG order form here.

Required clinicals:

  • Demographics
  • Labs & Tests Supporting Diagnoses 
  • Office/Progress Notes
Keytruda

E-Order (quickest option)

Download Keytruda order form here.

Require clinicals:

  • Demographics
  • Labs & Tests Supporting Diagnoses 
  • Office/Progress Notes
Kisunla

E-Order (quickest option)

Download Kisunla order form here.

Required clinicals: 

  • Baseline MRI within 1 year, with repeat MRIs needed prior to the 2nd, 3rd, 4th, and 7th infusion
  • Demographics
  • Labs & Tests Supporting Diagnoses 
  • Office/Progress Notes
Krystexxa

E-Order (quickest option)

Download Krystexxa order form here.

Required clinicals: 

  • Demographics
  • Labs & Tests Supporting Diagnoses 
  • Office/Progress Notes
  • G6PD results
  • Serum uric acid level within 1 month for initiation of therapy, within 48 hours for ongoing treatments
  • Documentation of the treatment plan regarding methotrexate use, including whether it will be initiated, continued, or withheld
Lamzede

E-Order (quickest option)

Download Lamzede order form here.

Required clinicals:

  • Demographics
  • Labs & Tests Supporting Diagnoses 
  • Office/Progress Notes
Leqembi

E-Order (quickest option)

Download Leqembi order form here.

Required clinicals: 

  • Baseline MRI within 1 year
  • Repeat MRIs needed prior to the 3rd, 5th, 7th and 14th infusion (more frequently if ARIA suspected)
  • Demographics
  • Labs & Tests Supporting Diagnoses
  • Office/Progress Notes
Leqvio

E-Order (quickest option)

Download Leqvio order form here.

Required clinicals: 

Lumvoa

E-Order (quickest option)

Download Lumvoa order form here.

Required clinicals:

  • Demographics
  • Labs & Tests Supporting Diagnoses
  • Office/Progress Notes
Nucala

E-Order (quickest option)

Download Nucala order form here.

Required clinicals: 

  • Demographics
  • Labs & Tests Supporting Diagnoses 
  • Office/Progress Notes
Nulojix

E-Order (quickest option)

Download Nulojix order form here.

Required clinicals: 

  • Demographics
  • Labs & Tests Supporting Diagnoses 
  • Office/Progress Notes
  • EBV serostatus
  • Negative TB results
Ocrevus

E-Order (quickest option)

Download Ocrevus order form here.

Required clinicals: 

  • Demographics
  • Labs & Tests Supporting Diagnoses 
  • Office/Progress Notes
  • Negative Hep B – HBsAg (Hepatitis B surface antigen) and Anti-HBc (Hepatitis B core antibody) 
  • Baseline liver function tests (LFTs) (ALT, AST, bilirubin, alkaline phosphatase) within 6 months for new starts
  • Serum immunoglobulins
Ocrevus Zunovo

E-Order (quickest option)

Download Ocrevus Zunovo form here.

Required clinicals: 

  • Demographics
  • Labs & Tests Supporting Diagnoses 
  • Office/Progress Notes
  • Negative Hep B – HBsAg (Hepatitis B surface antigen) and Anti-HBc (Hepatitis B core antibody) 
  • Baseline liver function tests (LFTs) (ALT, AST, bilirubin, alkaline phosphatase) within 6 months for new starts
  • Serum immunoglobulins
Omvoh

E-Order (quickest option)

Download Omvoh form here.

Required clinicals: 

  • Demographics
  • Labs & Tests Supporting Diagnoses 
  • Office/Progress Notes
  • Negative TB test
  • Baseline liver function tests (LFTs) (ALT, AST, bilirubin, alkaline phosphatase) within 6 months
  • Bilirubin within 6 months
Onpattro

E-Order (quickest option)

Download Onpattro order form here.

Required clinicals:

  • Demographics
  • Labs & Tests Supporting Diagnoses 
  • Office/Progress Notes
Opdivo Qvantig

E-Order (quickest option)

Download Opdivo Qvantig order form here.

Required clinicals:

  • Demographics
  • Labs & Tests Supporting Diagnoses 
  • Office/Progress Notes
Orencia

E-Order (quickest option)

Download Orencia order form here.

Required clinicals: 

  • Demographics
  • Labs & Tests Supporting Diagnoses 
  • Office/Progress Notes 
  • Negative TB screen
  • HBsAg (Hepatitis B surface antigen)
Papzimeos

E-Order (quickest option)

Download Papzimeos order form here.

Required clinicals: 

  • Demographics
  • Labs & Tests Supporting Diagnoses 
  • Office/Progress Notes 
Pasatru

Download Pasatru order form here.

Required clinicals: 

  • Demographics
  • Labs & Tests Supporting Diagnoses 
  • Office/Progress Notes 
Pemgarda

E-Order (quickest option)

Download Pemgarda order form here.

Download List of billable ICD-10 codes here.

Required clinicals:

  • Demographics
  • Labs & Tests Supporting Diagnoses 
  • Office/Progress Notes
Perjeta

E-Order (quickest option)

Download Perjeta order form here.

Required clinicals:

  • Demographics
  • Labs & Tests Supporting Diagnoses
  • Office/Progress Notes
  • Documented combination therapy of trastuzumab & chemotherapy
  • Confirmed HER2-Positive Status
Phesgo

E-Order (quickest option)

Download Phesgo order form here.

Required clinicals:

  • Documentation of which combined therapy patient is currently on
  • Demographics
  • Labs & Tests Supporting Diagnoses 
  • Office/Progress Notes
Prolia & Biosimilars

E-Order (quickest option)

Download Prolia & Biosimilars order form here

Required clinicals:

  • Demographics
  • Labs & Tests Supporting Diagnoses 
  • Office/Progress Notes
  • Serum calcium drawn within [60] days of the first dose. Must be within the lab’s normal reference range; if albumin is low, include albumin so calcium can be corrected.
  • Serum creatinine drawn within [60] days of the first dose
Remicade & Biosimilars

E-Order (quickest option)

Download Remicade & Biosimilars order form here.

Required clinicals: 

  • Demographics
  • Labs & Tests Supporting Diagnoses 
  • Office/Progress Notes
  • Negative TB screen
  • Negative Hep B – HBsAg (Hepatitis B surface antigen)
Rituxan & Biosimilars

E-Order (quickest option)

Download Rituxan & Biosimilars order form here.

Required clinicals: 

  • Demographics
  • Labs & Tests Supporting Diagnoses 
  • Office/Progress Notes
  • Negative Hep B – HBsAg (Hepatitis B surface antigen) and Anti-HBc (Hepatitis B core antibody)
Rystiggo

E-Order (quickest option)

Download Rystiggo order form here.

Required clinicals:

  • Demographics
  • Labs & Tests Supporting Diagnoses 
  • Office/Progress Notes
Saphnelo

E-Order (quickest option)

Download Saphnelo order form here.

Required clinicals:

  • Demographics
  • Labs & Tests Supporting Diagnoses 
  • Office/Progress Notes
Simponi Aria

E-Order (quickest option)

Download Simponi Aria order form here.

Required clinicals: 

  • Demographics
  • Labs & Tests Supporting Diagnoses 
  • Office/Progress Notes
  • Negative TB screen
  • Negative Hep B – HBsAg (Hepatitis B surface antigen)
Skyrizi

E-Order (quickest option)

Download Skyrizi order form here.

Required clinicals: 

  • Demographics
  • Labs & Tests Supporting Diagnoses 
  • Office/Progress Notes
  • Negative TB test
  • Baseline liver function tests (LFTs) (ALT, AST, bilirubin, alkaline phosphatase) within 6 months
  • Bilirubin within 6 months
Soliris & Biosimilars

E-Order (quickest option)

Download Soliris order form here.

Required clinicals: 

  • Demographics
  • Labs & Tests Supporting Diagnoses 
  • Office/Progress Notes
  • Urgent-start pathway: vaccinate as soon as possible plus antibacterial prophylaxis per REMS
Solu-Medrol

E-Order (quickest option)

Download Solu-Medrol order form here.

Required clinicals:

  • N/A
  • Demographics
  • Labs & Tests Supporting Diagnoses 
  • Office/Progress Notes
Spevigo

E-Order (quickest option)

Download Spevigo order form here.

Required clinicals: 

  • Negative TB
  • Demographics
  • Labs & Tests Supporting Diagnoses 
  • Office/Progress Notes
Stelara & Biosimilars

E-Order (quickest option)

Download Stelara & Biosimilars order forms here:

Required clinicals: 

  • Negative TB
  • Demographics
  • Labs & Tests Supporting Diagnoses 
  • Office/Progress Notes
Tepezza

E-Order (quickest option)

Download Tepezza order form here.

Required clinicals: 

  • Demographics
  • Labs & Tests Supporting Diagnoses 
  • Office/Progress Notes
Tezspire

E-Order (quickest option)

Download Tezspire order form here.

Required clinicals:

  • Demographics
  • Labs & Tests Supporting Diagnoses 
  • Office/Progress Notes
Tremfya

E-Order (quickest option)

Download Tremfya order form here. 

Required clinicals: 

  • Negative TB test
  • Demographics
  • Labs & Tests Supporting Diagnoses 
  • Office/Progress Notes
Tyruko

E-Order (quickest option)

Download Tyruko order form here.

Required clinicals:

  • Demographics
  • Labs & Tests Supporting Diagnoses 
  • Office/Progress Notes
  • Tyruko REMS enrollment
Tysabri

E-Order (quickest option)

Download Tysabri order form here.

Required clinicals:

  • Demographics
  • Labs & Tests Supporting Diagnoses 
  • Office/Progress Notes
  • TOUCH portal enrollment
Ultomiris

E-Order (quickest option)

Download Ultomiris order form here.

Required clinicals: 

  • Demographics
  • Labs & Tests Supporting Diagnoses 
  • Office/Progress Notes
  • Urgent-start pathway: vaccinate as soon as possible plus antibacterial prophylaxis per REMS
Uplizna

E-Order (quickest option)

Download Uplizna order form here.

Required clinicals: 

  • Demographics
  • Labs & Tests Supporting Diagnoses 
  • Office/Progress Notes
  • Negative Hep B – HBsAg (Hepatitis B surface antigen) and Anti-HBc (Hepatitis B core antibody)
Venofer

Due to increasing challenges with procurement, Local Infusion is currently only accepting limited iron referrals. Please contact your Local Infusion business development representative with additional questions.

Vyepti

E-Order (quickest option)

Download Vyepti order form here.

Required clinicals:

  • Demographics
  • Labs & Tests Supporting Diagnoses 
  • Office/Progress Notes
Vyvgart Hytrulo (Sub Q form of Vyvgart)

E-Order (quickest option)

Download Vyvgart Hytrulo form here.

Required clinicals:

  • Demographics
  • Labs & Tests Supporting Diagnoses 
  • Office/Progress Notes
Vyvgart

E-Order (quickest option)

Download Vyvgart order form here.

Required clinicals:

  • Demographics
  • Labs & Tests Supporting Diagnoses 
  • Office/Progress Notes
Xolair

E-Order (quickest option)

Download Xolair order form here.

Required clinicals:

  • Demographics
  • Labs & Tests Supporting Diagnoses 
  • Office/Progress Notes
Yeztugo

E-Order (quickest option)

Download Yeztugo order form here.

Required clinicals:

  • Individuals must have a negative HIV-1 test prior to initiating
Zoladex

E-Order (quickest option)

Download Zoladex order form here.

Required clinicals:

  • Demographics
  • Labs & Tests Supporting Diagnoses
  • Office/Progress Notes

We continue to expand our offering. Please contact us if you receive routine infusions with another therapy that you don’t see on this list.

Hate faxing?  You can also submit a digital order form and eSign. We’ll send you a copy for your records.