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Soliris (Eculizumab) Infusion Order

Patient First Name

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Patient Last Name

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Email

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Date of Birth

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Sex

Male

Female

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Diagnosis (please provide ICD10 code)

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Other

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Allergies

NKDA (No Known Drug Allergies)

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Allergies (please specify)

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Therapy

New Therapy Order

Continuation of Therapy

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Date of last dose

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Ordering Provider

Ordering Provider

Ordering Provider Name

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Provider NPI

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Phone

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Fax

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Practice Address

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City

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State

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Zip Code

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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.

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)

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Other pre-medication (specify)

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Soliris is a weight-based medication

Soliris is a weight-based medication

Patient Height (cm)

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Patient Weight (kg)

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Soliris Medication Order

Soliris Medication Order

aHUS, Myasthenia Gravis, and NMOSD (Adults)

Order type (choose one)

Induction Dosing followed by maintenance

Maintenance dosing every 2 weeks

Please select an option.

Induction IV Dosing: 900mg once weekly for 4 weeks, followed by 1200mg at week 5

Please mark this checkbox.

Maintenance Frequency after Induction: 1200mg every two weeks

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Maintenance-only IV Dosing: 1200mg

Please mark this checkbox.

aHUS (Pediatrics)

Order type (choose one)

Induction Dosing followed by maintenance

Maintenance dosing only

Please select an option.

Induction IV Dosing (choose one, by weight)

If >40kg, 900mg once weekly for 4 weeks, followed by 1200mg at week 5

If 30kg to ≤40kg, 600mg once weekly for 2 weeks, followed by 900mg at week 5

If 20kg to ≤30kg, 600mg once weekly for 2 weeks, followed by 600mg at week 3

If 10kg to ≤20kg, 600mg once, followed by 300mg at week 2

If 5kg to ≤10kg, 300mg once, followed by 300mg at week 2

Please select an option.

Maintenance Frequency after Induction (choose one, matching weight tier)

1200mg every two weeks

900mg every two weeks

600mg every two weeks

300mg every two weeks

300mg every three weeks

Please select an option.

Maintenance-only IV Dosing (choose one, by weight)

1200mg every two weeks

900mg every two weeks

600mg every two weeks

300mg every two weeks

300mg every three weeks

Please select an option.

PNH (Adults)

Order type (choose one)

Induction Dosing followed by maintenance

Maintenance dosing every 2 weeks

Please select an option.

Induction IV Dosing: 600mg once weekly for 4 weeks, followed by 1200mg at week 5

Please mark this checkbox.

Maintenance Frequency after Induction: 900mg every two weeks

Please mark this checkbox.

Maintenance-only IV Dosing: 900mg

Please mark this checkbox.

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.

Soliris-REMS program enrollment

Please mark this checkbox.

Documentation of meningococcal vaccines

Please mark this checkbox.

Brain MRI (within one year)

Please mark this checkbox.

Acetylcholine Receptor Antibody Test Results (if gMG)

Please mark this checkbox.

List of tried & failed therapies (if gMG)

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Aquaporin 4 Antibody Test Results (if NMO)

Please mark this checkbox.

Other required documentation

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Please upload the requested files

Click to upload files

Please upload a file.

Additional Instructions/Notes

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Patient IV Access

IV Access (choose one)

PIV

Use patient's SL/DL PICC, flush per protocol

Access/deaccess patient's Port, flush per protocol

Please select an option.

*Imaging results of proper placement required for PICC/Port

Choose an office:

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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

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Date

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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

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Phone

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

Please upload the requested files

Click to upload files

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