Senderra Specialty Pharmacy Patient & Medical Information Form

Faxed prescriptions will only be accepted from a prescribing practitioner. Patients must bring an original prescription to the pharmacy, and cannot fax these referral forms to Senderra.

Prescribing Practitioner:

Cardiovascular

Enrollment

NPI:

Address:

Office:

Fax:

Main: 888-777-5547

Fax: 888-777-5645

Contact:

1301 E. Arapaho Rd., Ste. 101

Richardson, TX 75081

E-mail:

PATIENT INFORMATION

Name:

DOB:

SS#:

M

F

_____/_____/__________

_____-_____-__________

Tel:

Al. Tel:

Wt.:

Ht.:

English

Spanish

Other: ________

________

________

Street:

City:

State:

ZIP:

MEDICAL INFORMATION

Statins:

Tried & Failed (Duration):

Not Tolerated:

Contraindication:

Allergies:

Simvastatin

(___________________)

______________________________

Atorvastatin

(___________________)

______________________________

________________

(___________________)

______________________________

Other therapies:

Tried & Failed (Duration):

Not Tolerated:

Contraindication:

Zetia

(___________________)

______________________________

LDL apheresis

(___________________)

______________________________

________________

(___________________)

______________________________

Date of Diagnosis: _____/______/________

Indicate One Primary Diagnosis:

Indicate One Secondary Diagnosis:

E78.0 Pure Hypercholesterolemia (HeFH and HoFH)

I21.__ Acute Myocardial Infarction

I6_.__ Occlusion of Cerebral Arteries (CVA)

E78.2 Mixed Hyperlipidemia

I25.2 Old Myocardial Infarction

G45.__ Transient Cerebral Ischemia (TIA)

I20.8 Other and Unspecified Angina

I67.__ Other and Ill-Defined

E78.5 Other and Unspecified Hyperlipidemia

Pectoris

Cerebrovascular Disease

I25.__ Other Forms of Chronic Ischemic

Other: __________________________________________

Heart Disease

I69.__ History of Stroke With Residuals

I25.10 ASCVD, Unspecified

I70.__ Atherosclerosis

I65.__ Occlusion and Stenosis of

I73.9 Peripheral Vascular Disease,

Precerebral Arteries

Unspecified

***PLEASE FAX COPY OF PRESCRIPTION/MEDICAL CARD, FRONT AND BACK, AS WELL AS ANY CLINICAL NOTES REGARDING THERAPY***

PRESCRIPTION

New

Refill

Ship by: ____/____/____

SHIP TO:

Patient’s Home

Doctor’s Office

Other: ___________________

Refills

Drug

Strength

Directions & Quantity

140mg/mL SureClick autoinjector

Inject 140mg subcutaneously every 2 weeks

(quantity: 2)

Repatha™

Inject 420mg subcutaneously once monthly

(quantity: 3)

140mg/mL pre-filled syringe

*To administer 420mg, give 3 Repatha injections consecutively within 30 minutes*

Pre-Filled Pen

Inject 75mg subcutaneously every 2 weeks (quantity: 2)

Praluent®

Pre-Filled Syringe

Inject 150mg subcutaneously every 2 weeks (quantity: 2)

INJECTION TRAINING

Patient has received pen and injection training

Physician’s office to provide injection training

Senderra Rx to coordinate injection training

PRESCRIBING PRACTITIONER SIGNATURE

To Prescribing Practitioner: By signing this form and utilizing our services, you are also authorizing Senderra Rx to serve as your prior authorization designated agent in dealing with medical

and prescription insurance companies, and co-pay assistance foundations.

Prescribing

Practitioner:

Date:

_______/________/____________

CONFIDENTIALITY NOTICE

IMPORTANT: This fax is intended to be delivered only to the named addressee. It contains material that is confidential, proprietary or exempt from disclosure under applicable law. If you are not the

named addressee, you should not disseminate, distribute, or copy this fax. Please notify the sender immediately if you have received this document in error and then destroy this document immediately.

Cardiovascular Enrollment (Rev. 04/28/2016)