Prolia Form

* = Required Information

Today's Date

Anticipated Start Date *

Patient Information

Patient Name *

Address

City

State

Zip Code

Work Phone

Cell Phone

Social Security Number

Date of Birth

Gender

Male

Female

PRESCRIBER INFORMATION

Physician Name

Specialty

Site Name

Address

City

State

Zip Code

Phone

Fax

Email Address *

Office Contact

NPI

PERTINENT MEDICAL INFORMATION

733.00 Osteoporosis, unspecified

733.01 Senile osteoporosis, postmenopausal osteoporosis

Other (specify ICD-9-CM)

T-Score (if known)

History of osteoporosis fracture

Yes

Not known

Skeletal Site (if known)

Other risk factors for osteoporosis fracture (if any)

Prior Postmenopausal Osteoporosis Treatment History (if any)

Generic Alendronate

Fosamax(alendronate sodium)

Actonel (risedronate sodium)

Boniva (ibandronate sodium)

Other

Reason for Discontinuing Previous Osteoporosis Therapy(ies)

Contraindications (if any)

Other pertinent medical information (eg. Calcium and vitamin D supplementation)

* The sample diagnosis codes are informational and not intended to be directive or guarantee of reimbursement and include potential codes that would include FDA-approved indications for Prolia. Other codes may be more appropriate given internal system guidelines, payor requirements, practice patterns, and the service rendered.

PHARMACY INSURANCE INFORMATION. (Note: For Medicare patients, provide Pharmacy Insurance Information)

Check one of the following:

Attach a copy of insurance card front AND back OR provide:

Name of Insurer

Policy #

Insurance Patient ID #

Insurance Telephone #

PRESCRIPTION INFORMATION

Product Name/Strength: Prolia 60mg prefilled syringe

Directions: 60mg SC every 6 months

Refill

State Licence Number

DEA #

Ship to

Physician Office

Patient

Prescriber Signature:

Date

Key Safety considerations for Prolia include: hypocalcemia, serious infections, dermatologic adverse events,osteonecrosis of the jaw, and long-term suppression of bone remodeling.

IMPORTANT NOTICE: This fax is intended to be delivered only to the named addressee. It contains material that is confidential, privileged, proprietary or exempt from disclosure under applicable law. If you are not the named addressee, you should not disseminate, distribute, or copy this fax. Please notify the sender immediately if you have received this document in error and then destroy this document immediately. PLEASE NOTE: Newport Pharmacy can only accept original prescription drug orders from patients, faxed prescriptions can be accepted only from the prescribing practitioners.