Makena Specialty Order Form

Makena Specialty Order Form
Prescriber's Name:
MD / DO / NP / PA
Address:
City
Phone: 844-428-7387
Fax: 844-228-7387
State
Office Contact:
Office Contact:
Phone#
Phone#
NPI:
PATIENT INFORMATION
Send updates to
Fax
Fax#
Fax#
DEA:
Tax ID:
E-mail to _________________________
Patient's Name:
Zip
Text to Phone# _________________
DOB:
SS#
Address:
City
Home Phone:
State
Work or Cell:
Allergies:
Emergency Contact:
Sex: M____ F____ Wt:
Patient previously on treatment: Y N Date:
Primary Insurance:
Zip
Diabetic:
Ht:
African American
Caucasian
Native American
Other
Y
N
Asian
Latin/Hispanic
Pacific Islander
Insured:
Please send copy of Insurance Card
* Please include current patient medication list with referral *
DIAGNOSIS INFORMATION
Primary ICD-9:________________________________________________________________________________________________
Secondary ICD-9:___________________________________________ Other ICD-9 Code:__________________________________
CLINICAL INFORMAATION – Please complete in entirety.
CURREN PREGNANCY:
Current Gestational Age: _____ weeks _____ days
Date Recorded: _______________
Yes
No Is the patient pregnant with a singleton?
Yes
Yes
No Is the patient experiencing preterm labor?
No Does the patient have a cerclage?
Where will the Medication be administered?
Office
Home
Anticipated Start Date
Gravida:
Para:
0
0
1
1
2
2
3
3
Other: _______
Other: _______
Gestational Age of prior preterm birth: ______ weeks
Yes
No Has the patient had a previous spontaneous singleton
preterm birth (earlier than 37 weeks gestation)?
Yes
No Has the patient had any previous preterm birth?
If yes, please check indication(s) that apply:
If Home, please list CPT code requested ________
TREATMENT ARRANGEMENTS
OB HISTORY:
Multiple gestation
Fetal complications
Home
Doctors Office
Ship Meds:
Aureus
Teaching by:
Drs. Office
Maternal complications
Incompetent cervix
Lab in Box: Y or N
Other
Rx: Makena® (hydroxyprogesterone caproate injection)
250mg / mL multidose vial
Dispense 1 vial, followed by ____ refills for a complete
course of therapy
Sig: Inject 1mL IM each week
By
By signing
signingthis
this form
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and utilizing
utilizing our
our services,
services,you
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serveas
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medical and prescription insurance
insurance companies.
Prescriber Signature:
May Substitute
Dispense as Written
Date:
Form Form
# - Makena-090514
# - HEP-041514