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Ultomiris (Ravulizumab-cwvz) 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

Please select an option.

Diagnosis (please provide ICD10 code)

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Other

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Allergies

NKDA (No Known Drug Allergies)

Please mark this checkbox.

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

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

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)

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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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Ultomiris is a weight based drug

Ultomiris is a weight based drug

Patient Height (cm)

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Patient Weight (kg)

Please complete this field.

Ultomiris Medication Order (Please select ONE)

Order type

Induction dosing on week 0, 2 followed by maintenance

Maintenance dosing every 8 weeks only

Please select an option.

IV Dosing for week 0 (choose one, by weight)

2400 mg (40kg—59.9kg)

2700 mg (60kg—99.9kg)

3000 mg (>100kg)

Please select an option.

Maintenance Dosing for week 2 and every 8 weeks (choose one, by weight)

3000 mg (40kg—59.9kg)

3300 mg (60kg—99.9kg)

3600 mg (>100kg)

Please select an option.

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

3000 mg (40kg—59.9kg)

3300 mg (60kg—99.9kg)

3600 mg (>100kg)

Please select an option.

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.

Proof of Meningitis Vaccines (both conjugate and serogroup)

Please mark this checkbox.

ACH Antibody positive

Please mark this checkbox.

CBC/CMP

Please mark this checkbox.

Brain MRI within the last 6 months

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

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Best Contact Person in Office

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Phone

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

Please upload the requested files

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