Complete the form below and attach signed orders, current labs, history and physical, then click submit. We’ll review at our earliest convenience and contact you to confirm acceptance of service. You can also call us toll-free at 877-501-6800 to start the referral process.

Choose an IVIG course:
IVIG grams daily for day(s).
IVIG grams/kilogram daily given over non-consecutive day(s).
Repeat course every week(s) for a total of course(s). OK to round dose to nearest vial size.

Choose an SQIG course:
SQIG grams each month given as dose.
SQIG grams times per month.
Administer SQIG using sites at a time. Repeat week(s). OK to round does to nearest vial size.

Refill x 1 year. If needed, a Basic Metabolic Panel (Chem7) to be drawn prior to first dose. If ncessary Patient may have first dose administered in the home by a skilled nurse, unless instructed otherwise. Anaphylaxis kit per protocol, refill x 1 year.

Please combine multiple documents into a single PDF (watch a guide) or ZIP file (watch a guide).

    • Immunoglobulin order: included dose, route of administration, frequency, duration, and any premedications OR use Rx order section above.
    • Patient demographis: include insurance information. We will obtain authorization unless the insurance dictates otherwise.
    • H & P OR progress note(s) describing diagnosis and clinical status.
    • Labs: BUN/Creatinine (preferred with in last 90 days) and IgA.

CONFIDENTIALITY NOTICE: This document includes confidential, propretary information that is the sole exclusive property of Apex Infusion Pharmacy. No rights in, relating to, or derived from such information are assigned or otherwise transferred by this document, and the receipient of such information is subject to obligations of secrecy to and for the benefit of Apex Infusion Pharmacy. Any unauthrized use or disclosure of such information is stricly prohibited. this message, together with any attachments, is intended only for the use of the individual or entitiy to which it is addressed an may contain information that is confidential and prohibited from disclosure. If you are not the intended recipient, you are hereby notified that any dissemination, or copying of this message, or any attachment, is strictly probhibited. If you have received this message in error, please notify the original sender immediately by thelphone or by return fax and shred this document along with any other documents. Thank you.