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Rituxan Referral Form

  /  Rituxan Referral Form
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    Diagnosis/Code:

    ► Please check the box corresponding to the weight used for dose calculation.
     
     

     

    ► Laboratory or Other Tests Related to Chemotherapy:

    ► Dosing Guidelines/ Parameters: Provider must select one option below

    Hydration Orders: Not Required
    DRUG DOSE ROUTE RATE FREQUENCY, DAYS TO BE GIVEN
    PO _____ 30 minutes pre treatment
    PO _____ 30 minutes pre treatment
    IVP

    ► Treatment Orders:
    DRUG: DOSE CALCULATION DOSE SOLUTION AND VOLUME ROUTEU RATE DAYS TO BE GIVEN
    Mix as a 1:1 mixture IVPB Initiate at 50mg/hr x 30 min Increase rate by 50mg q30 min to a max rate of 400mg/hr Infuse the remainder at 400mg/hr 1st dose only
    Mix as a 1:1 mixture IVPB Initiate at 100mg/hr x 30 min Increase rate by 100mg q30 min to a max rate of 400mg/hr Infuse the remainder at 400mg/hr

    Mix as a 1:1 mixture IVPB Rapid Rituxan Infuse 20% of dose over 30 minutes with rest infusing over 1 hour
    Date of first treatment: Date taken: /subsequent treatments may be given +/- 5 days for greater than weekly This order is good for 1 year from the date ordered

    ► Call referring provider for:
    Phone: Fax: Email:
    ► PROVIDER SIGNATURE:


     
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    Address

    5030 Camino De La Siesta
    Suite 106
    San Diego, CA 92108

    Phone

    (619) 334 4869

    Fax

    (619) 334 4940

    Email

    info@nycmediastudio.com

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    Cabrillo Infusion Center is a stand-alone Infusion center founder in 2013.
    Cabrillo Infusion focuses on both chronic and acute therapies including the following: Immunoglobulin (IV & SQ), Antibiotics, total Parenteral Nutrition and Enteral therapies.

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    Copyright © 2010 Cabrillo Center For Rheumatic Disease — All rights reserved.