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Referral Order Forms

At Medix Infusion, we can administer or dispense a multitude of infusion and injectable therapies through both a patient’s major medical and pharmacy benefits. Below you will find downloadable order forms for the most common therapies requested. If you do not see the medication your patient requires, please contact us directly here or fill out this Blank Infusion Order Form. Our formulary team can quickly review the request to determine if we can provide the medication.

Completed Order Forms can be faxed to 972.499.9210.

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Actemra (tocilizumab)

Actemra (tocilizumab) – Pediatric

Alpha1-Proteinase Inhibitor 

Anti-Infectives (Antibiotics, Antivirals, & Antifungals)

Avsola (infliximab-axxq)

Benlysta  (belimumab)

Blank Infusion Order Form

Cimzia (certolizumab-pegol)

Cinqair  (reslizumab)

Cuvitru  (Immune Globulin SubQ)

Dalvance (dalbavancin)

Entyvio (vedolizumab)

Fasenra (benralizumab)

HyQvia (Immune Globulin SubQ)

Ilumya (tildrakizumab-asmn)

Immune Globulin (IV)

Immune Globulin (SubQ)

Inflectra (infliximab-dyyb)

Injectafer (ferric carboxymaltose)

Kimyrsa (oritavancin)

Krystexxa (pegloticase)

Leqvio (inclisiran)

Nucala (mepolizumab)

Nulojix (belatacept)

Ocrevus (ocrelizumab)

Onpattro (patisiran)

Orbactiv (oritavancin)

Orencia (abatacept)

Radicava  (edaravone)

Remicade (infliximab)

Renflexis (infliximab-abda)

Rituxan (rituximab)

Ruxience (rituximab-pvvr)

Stelara IV (ustekinumab)

Simponi Aria (golimumab)

Soliris (eculizumab)

Tepezza (teprotumumab-trbw)

Truxima (rituximab-abbs)

Xolair (omalizumab)