Leqvio (Inclisiran) Injection Order
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Diagnosis
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Allergies
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Ordering Provider
Ordering Provider
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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.
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Patient Height and Weight
Patient Height and Weight
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Required Documentation
Required Documentation
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Leqvio Medication Order (Please select ONE)
Select the order type below. The dosing shown is fixed for each option.
If Induction dosing on months 0 and 3, followed by maintenance
Dosing: 284 mg subcutaneous injection. Maintenance Frequency: Every 6 months.
If Maintenance dosing every 6 months only
Dosing: 284 mg subcutaneous injection.
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Ordering Provider Signature
Ordering Provider Signature
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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.