Patient Identifier:
Name:
PHN:
Intravenous Immune Globulin
(IVIg)/Subcutaneous Immune Globulin
(SCIG) Physician Request Form
DOB:
Date of Completion:
IVIg formulation:
Weight (kg):
Duration of therapy:
No preference
Gamunex®
Requested dose:
Single use
treatments
Ordering Physician:
CLINICAL INDICATION
Dermatology
Octagam®
Privigen®
g / day x
days, q
other
SCIG
weeks
Consultant Physician (if applicable):
Physician Specialty:
Pemphigus Vulgaris
Hematology
Hemolytic disease of the fetus and newborn
ITP
Neonatal alloimmune thrombocytopenia
Post transfusion purpura
Immunology
Primary immune deficiency
Secondary immune deficiency (Primary diagnosis
______________________ )
Infectious Disease
Group A Streptococcal fasciitis
Neurology
Chronic Inflammatory Demyelinating Polyneuropathy
Guillian-Barre syndrome
Lambert-Eaton Myasthenic syndrome
Multifocal Motor Neuropathy
Myasthenia Gravis
Stiff person syndrome
Rheumatology
Dermatomyositis
Polymyositis
Staphylococcal Toxic Shock
Kawasaki Disease
If patient does not meet above indications,
Diagnosis:
Infusion site:
Changes to treatment:
(Multiple Infusion patients)
Document F160-INV16A V01
WRHA
Southern
Institution:
Northern
Interlake-Eastern
Dose changed
Subcutaneous route
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Prairie Mountain
Treatment discontinued
N/A
patient deceased Date:
Effective Date:
Instructions for Completion of IVIG Order Form
This Order Form is to accompany Requests to Release Forms:
1. Initial order for one time infusion
2. Initial order for multiple infusions
3. Subsequent orders for multiple infusions
a. Dose is modified
b. Six months have lapsed from initial treatment
c. Twelve months have elapsed since the initial treatment for Primary
immune Deficiency.
Completing the Form:
The Treating Physician or designate:
1. Addressograph or use patient identification sticker
2. Complete the date of completion
3. Complete the preferred IVIG formulation.
4. Document the patient height and weight.
5. Identify the total dose per treatment and the duration of the treatment.
6. Identify the Treating Physician, their Specialty and if a consult has occurred,
the consulting physician.
7. Check the appropriate box to identify the clinical indication.
8. Check “Other” if the clinical indication does not appear on the list.
9. Identify where the infusions will occur or SCIG is obtained.
10. Indicate if the form completion is due to Changes to treatment.
Site Blood Bank
1. Verify all information is complete on order form
2. Add patient name, phn, physician and date to the IVIG site specific patient
log.
Document F160-INV16A V01
Page 2 of 2
Effective Date: