Skip Navigation

Accessibility Options

Contrast

Text

Visual

Report An Issue

(opens in new tab)

About
Infusion Therapies
- Greater Chicago Area
- Houston Area
Conditions We Treat
For Patients
For Providers
Resources
- Testimonials
Visit Us
Our Locations
Order Forms

Our new Orland Park location is opening soon!

Skip Main Content

Ilaris (Canakinumab) Injection Order

Patient First Name

Please complete this field.

Patient Last Name

Please complete this field.

Email

Please complete this field.

Date of Birth

Please complete this field.

Sex

Male

Female

Please select an option.

Diagnosis (please provide ICD10 code)

Please complete this field.

Other

Please complete this field.

Allergies

NKDA (No Known Drug Allergies)

Please mark this checkbox.

Allergies (please specify)

Please complete this field.

Therapy

New Therapy Order

Continuation of Therapy

Please select an option.

Date of last dose

Please complete this field.

Ordering Provider

Ordering Provider

Ordering Provider Name

Please complete this field.

Provider NPI

Please complete this field.

Phone

Please enter a 10-digit phone number (numbers only).

Fax

Please enter a 10-digit phone number (numbers only).

Practice Address

Please complete this field.

City

Please complete this field.

State

Please complete this field.

Zip Code

Please complete this field.

Pre-Medication

Pre-Medication

Select each pre-medication ordered below. Then use the Pre-Medication dosing details field to specify the dose (mg) and route for each medication selected.

Acetaminophen (route: PO)

Please mark this checkbox.

Cetirizine (route: PO)

Please mark this checkbox.

Diphenhydramine (route: PO or IVP)

Please mark this checkbox.

Solu-Medrol (route: PO or IVP)

Please mark this checkbox.

Solu-Cortef (route: PO or IVP)

Please mark this checkbox.

Pre-Medication dosing details (specify mg and route for each drug selected)

Please complete this field.

Other pre-medication (specify)

Please complete this field.

Ilaris is a weight based drug

Ilaris is a weight based drug

Patient Height (cm)

Please complete this field.

Patient Weight (kg)

Please complete this field.

Ilaris Subcutaneous Medication Order

Ilaris Subcutaneous Medication Order

Adult-Onset Still's Disease and Systemic Juvenile Idiopathic Arthritis

4mg/kg (max 300mg) with patients 7.5kg and over every 4 weeks

Please mark this checkbox.

Cryopyrin-Associated Periodic Syndromes (CAPS) (choose one)

Dosing

Patients > 40kg, 150mg every 8 weeks

Patients between 15kg and 40kg, 2mg/kg every 8 weeks

Please select an option.

TRAPS / HIDS / Mevalonate Kinase Deficiency / Familial Mediterranean Fever - Dosage for patients ≤ 40kg (choose one)

Dosing

2mg/kg every 4 weeks

4mg/kg every 4 weeks

Please select an option.

TRAPS / HIDS / Mevalonate Kinase Deficiency / Familial Mediterranean Fever - Dosage for patients > 40kg (choose one)

Dosing

150mg every 4 weeks

300mg every 4 weeks

Please select an option.

Gout Flares

Single-dose of 150mg

Please mark this checkbox.

Re-treatments need at least 12 weeks before a new dose can be administered. New script will be needed.

Required Documentation

Required Documentation

Patient Demographics

Please mark this checkbox.

Patient Insurance (med and pharm card copies, front and back)

Please mark this checkbox.

Progress Notes/Labs supporting diagnosis

Please mark this checkbox.

Quantiferon lab results

Please mark this checkbox.

Other required documentation

Please complete this field.

Please upload the requested files

Click to upload files

Please upload a file.

Additional Instructions/Notes

Please complete this field.

Choose an office:

Please select an office.

Ordering Provider Signature

Ordering Provider Signature

Please sign your name in the area below

By submitting your signature, the parties agree that this agreement may be electronically signed. The parties agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

E-signature image

Provider

Please complete this field.

Date

Please complete this field.

Phone

Please enter a 10-digit phone number (numbers only).

Fax

Please enter a 10-digit phone number (numbers only).

Best Contact Person in Office

Please complete this field.

Phone

Please enter a 10-digit phone number (numbers only).

Please upload the requested files

Click to upload files

Subscribe to updates from Infusacare

Thank you for subscribing!

You will receive important news and updates from our practice directly to your inbox.

Thanks!

Your form has been successfully submitted!

We will be in touch with you if additional information is needed.

Thanks!

Opt-out of using e-signatures?

Are you sure you want to opt-out of using e-signatures? You will be required to fill this form out again during your visit on a paper copy.

Download a copy of your signed form

Click the button below to download a PDF copy of your form

Quick Links
Conditions Treated

Subscribe to Our Updates

Please enter a valid email.

Our Locations CONTACT US

(opens in new tab)

POWERED BY

(opens in new tab)

Privacy Policy(opens in new tab)Data Security(opens in new tab)HIPAA(opens in new tab)Terms of Use(opens in new tab)

Copyright 2026 Infusacare