sage infusionClearwater: Phone: 727.977.9717 I Fax:
727.977.9717Tampa: Phone: 813.775.9997 I Fax: 813.775.9997Email:
[email protected] I Online: www.sageinfusion.com
(natalizumab)
TYSABRI infusion ordersPatient Name DOB
-----------------
Phone
DIAGNOSIS Please provide ICO-10 code
D ___ Multiple Sclerosis D Crohn 1s Disease
PRE-MEDICATION
□ Tylenol 1000mg POD Diphenhydramine 25mg POD Cetirizine 10mg
PO
□---------,--,--,-(other)
TYSABRI ORDERS
DOSAGE @ 300mg IV
FREQUENCY ® every 4 weeks for ___ treatments
LAST DOSAGE OF: 0 Avonex O Betaseron O Rebif
NOTES
ORDERING PROVIDER
MO FQ
□--
□ Solu-Medrol 125mg IVPD Solu-Cortef 100mg IVP
(other)
D Diphenhydramine 25mg IVP
□---------,--,--,-(other)
PATIENT WEIGHT ___ lbs.
___ kg
Date of last dose: -----
Signature ..;;_X�--------------------,- Date _____ _
v1.1 Sage Infusion LLC
