Local Infusion

Outpatient Infusion Services

Submit an order form by fax or email


Download and print the therapy-specific order form below.
You can fax or email the completed form, along with supporting clinicals.

You can email or fax directly to your Local Infusion center, fax numbers for each location can be found on the therapy-specific forms below, as well as on our Locations page.

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

Actemra

E-Order (quickest option)

Download Actemra order form here.

Required clinicals:

  • Negative TB screen
  • 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
Altuviiio

E-Order (quickest option)

Download Altuviiio order form here.

Required clinicals:

  • Demographics
  • Labs & Tests Supporting Diagnoses
  • Office/Progress Notes
  • Factor VIII inhibitor testing within the past 30 days
Amvuttra

E-Order (quickest option)

Download Amvuttra order form here.

Required clinicals:

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

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

  • Negative TB screen
  • Negative Hepatitis
  • 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
Crysvita

E-Order (quickest option)

Download Crysvita order form here.

Required clinicals: 

  • Serum phosphorus within 6 months of referral
  • Serum creatinine within 6 months of referral
  • 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
Entyvio

E-Order (quickest option)

Download Entyvio order form here.

Required clinicals: 

  • Negative TB results
  • 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:

  • Negative Hep B
  • Demographics
  • Labs & Tests Supporting Diagnoses 
  • Office/Progress Notes
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
Hydration

E-Order (quickest option)

Download Hydration order form here.

Required clinicals: 

BASELINE BLOOD WORK

  • All patients must have documented BUN and Cr levels within 6 months prior to starting routine IV fluid therapy.
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
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: 

  • G6PD results
  • Serum uric acid level within 1 month for initiation of therapy, within 48 hours for ongoing treatments
  • Documentation of initiation of Methotrexate and folic acid
  • Demographics
  • Labs & Tests Supporting Diagnoses 
  • Office/Progress Notes
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: 

Magnesium Sulfate

E-Order (quickest option)

Download Magnesium Sulfate order form here.

Required clinicals:

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

E-Order (quickest option)

Download Monoferric order form here.

Required clinicals: 

  • Demographics
  • Labs & Tests Supporting Diagnoses 
  • Office/Progress Notes
  • (CBC) and iron studies (ferritin and/or iron level) that demonstrate iron deficiency/anemia within 6 months of initiation of therapy
  • **If referring office sending over someone with “WNL” lab values- documentation of explanation of why treatment is being ordered/recommended will be required.
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: 

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

E-Order (quickest option)

Download Ocrevus order form here.

Required clinicals: 

  • Negative Hep B
  • Demographics
  • Labs & Tests Supporting Diagnoses 
  • Office/Progress Notes
  • Baseline liver function tests (LFTs) (ALT, AST, bilirubin, alkaline phosphatase) within 6 months
Ocrevus Zunovo

E-Order (quickest option)

Download Ocrevus Zunovo form here.

Required clinicals: 

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

E-Order (quickest option)

Download Omvoh form here.

Required clinicals: 

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

E-Order (quickest option)

Download Onpattro 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: 

  • Negative TB 
  • Negative Hep B 
  • 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 & Biosimilar order form here

Required clinicals:

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

E-Order (quickest option)

Download Qutenza order form here.

https://qutenzahcp.com/pdfs/M-QZA-US-12-21-0010_QUTENZA-Patient-Chart-Documentation-Form.pdf

Required clinicals:

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

E-Order (quickest option)

Download Reclast order form here.

Required clinicals: 

  • Normal calcium within 6 months of referral
  • Serum creatinine within 6 months of referral
  • Calculated creatinine clearance MUST be greater than 30 mL/min using the Cockcroft-gault equation
  • Demographics
  • Labs & Tests Supporting Diagnoses 
  • Office/Progress Notes
Remicade & Biosimilars

E-Order (quickest option)

Download Remicade & Biosimilars order form here.

Required clinicals: 

  • Negative TB
  • Negative Hep B results
  • Demographics
  • Labs & Tests Supporting Diagnoses 
  • Office/Progress Notes
Rituxan & Biosimilars

E-Order (quickest option)

Download Rituxan & Biosimilars order form here.

Required clinicals: 

  • ​​​​Negative Hep B
  • Demographics
  • Labs & Tests Supporting Diagnoses 
  • Office/Progress Notes
Rystiggo

E-Order (quickest option)

Download Rystiggo order form here.

Required clinicals:

  • Demographics
  • Labs & Tests Supporting Diagnoses 
  • Office/Progress Notes
Sandostatin LAR Depot

E-Order (quickest option)

Download Sandostatin LAR Depot 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: 

  • Negative TB 
  • Negative Hep B
  • Demographics
  • Labs & Tests Supporting Diagnoses 
  • Office/Progress Notes
Skyrizi

E-Order (quickest option)

Download Skyrizi order form here.

Required clinicals: 

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

E-Order (quickest option)

Download Soliris order form here.

Required clinicals: 

  • Documentation of meningitis vaccine (at least 2 weeks before 1st infusion)
  • Demographics
  • Labs & Tests Supporting Diagnoses 
  • Office/Progress Notes
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: 

  • Thyroid panel within 6 months of referral prior to initiation of therapy
  • Hearing test completed prior to treatment
  • 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
Tyenne

E-Order (quickest option)

Download Tyenne order form here.

Required clinicals: 

  • Negative TB test
  • Within 6 months:
    • Absolute neutrophil count (above 2,000)
    • Platelet count (above 100,000)
    • ALT/AST – cannot be above 1.5 times the upper limit of normal
  • Demographics
  • Labs & Tests Supporting Diagnoses
  • Office/Progress Notes
Tyruko

E-Order (quickest option)

Download Tyruko order form here.

Required clinicals: 

  • Negative Hep B
  • Demographics
  • Labs & Tests Supporting Diagnoses
  • Office/Progress Notes
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: 

  • Proof of meningococcal vaccination at least 2 weeks prior to start of treatment (If urgent Ultomiris therapy is indicated in an unvaccinated patient, administer meningococcal vaccine(s) as soon as possible and provide patients with two weeks of antibacterial drug prophylaxis
  • Demographics
  • Labs & Tests Supporting Diagnoses 
  • Office/Progress Notes
Uplizna

E-Order (quickest option)

Download Uplizna order form here.

Required clinicals: 

  • Negative Hep B
  • Negative TB
  • Demographics
  • Labs & Tests Supporting Diagnoses 
  • Office/Progress Notes
Venofer

E-Order (quickest option)

Download Venofer order form here.

Required clinicals: 

  • Demographics
  • Labs & Tests Supporting Diagnoses 
  • Office/Progress Notes
  • (CBC) and iron studies (ferritin and/or iron level) that demonstrate iron deficiency/anemia within 6 months of initiation of therapy
  • **If sending over someone with “WNL” lab values- documentation of explanation of why treatment is being ordered/recommended will be required.
Vitamin B 12 Injection

E-Order (quickest option)

Download Vitamin B 12 Injection order form here.

Required clinicals:

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

E-Order (quickest option)

Download Xgeva order form here.

Required clinicals: 

  • Normal calcium within 6 months of referral
  • 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

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.