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Medical Day Care Order Forms

Thank you for choosing Cooley Dickinson Medical Day Care for your patient. When sending patient orders, please select, download, print and fax the most appropriate order form from the folders below.

When filling out an order form, please:

  • fill out the entire form, including your signature and any Medical Necessity questions.
  • remember to order the primary medication, and any associated pre- or emergency-medications

When faxing order forms:

  • Fax to Cooley Dickinson Central Scheduling at 413-582-2183, all of the following:
    • the completed order form
    • the patient’s current H&P
    • a listing of the patient’s current medications & allergies
    • any signed consents that might be required for treatment

If you have any questions, please contact the Cooley Dickinson department that most closely suits your inquiry:

Central Scheduling: 413-582-5000

Medical Day Care:  413-582-2920

Pharmacy:  413-582-2116

 

DOWNLOAD FORMS HERE:


 Blood Transfusions
208-201 Blood Transfusions 208-201 Blood Transfusions  21-12 info AND consent  1 17 21-12 info AND consent  1 17

Injections & IV Therapy
208-200 MDC combined Order Set form 9.17 208-200 MDC combined Order Set form 9.17

Infusions (“Therapy Plans”)
208-202 INFLIXIMAB DERMATOLOGY LOAD 2.18 208-202 INFLIXIMAB DERMATOLOGY LOAD 2.18 208-230 SODIUM FERRIC GLUCONATE 208-230 SODIUM FERRIC GLUCONATE
208-203 INFLIXIMAB GI LOAD (SCHEDULE WEEKS 0 2 6) 2.18 208-203 INFLIXIMAB GI LOAD (SCHEDULE WEEKS 0 2 6) 2.18 208-231 VEDOLIZUMAB MAINTENANCE 208-231 VEDOLIZUMAB MAINTENANCE
 208-204 ABATACEPT (ORENCIA) FOR RHEUMATOLOGY MAINTENANCE 208-204 ABATACEPT (ORENCIA) FOR RHEUMATOLOGY MAINTENANCE 208-232 CORTROSYN STIMULATION TEST 208-232 CORTROSYN STIMULATION TEST
208-205 BELIMUMAB 208-205 BELIMUMAB 208-233 INTRAVENOUS FERAHEME (FERUMOXYTOL) 208-233 INTRAVENOUS FERAHEME (FERUMOXYTOL)
208-206 INFLIXIMAB DERMATOLOGY MAINTENANCE 2.18 208-206 INFLIXIMAB DERMATOLOGY MAINTENANCE 2.18 208-234 ALBUMIN 208-234 ALBUMIN
208-207 INFLIXIMAB OPHTHALMOLOGY 208-207 INFLIXIMAB OPHTHALMOLOGY 208-235 ANTIBIOTICS 208-235 ANTIBIOTICS
208-208 XOLAIR 2.18 208-236 THYMOGLOBULIN 208-236 THYMOGLOBULIN
208-209 MEPOLIZUMAB 208-209 MEPOLIZUMAB 208-237 RITUXIMAB RHEUMATOLOGY VASCULITIS 208-237 RITUXIMAB RHEUMATOLOGY VASCULITIS
208-210 INFLIXIMAB RHEUMATOLOGY MAINTENANCE 2.18 208-210 INFLIXIMAB RHEUMATOLOGY MAINTENANCE 2.18 208-238 RITUXIMAB DERMATOLOGY (RA PROTOCOL 1000MG X 2 DOSES 2 WEEKS APART) 208-238 RITUXIMAB DERMATOLOGY (RA PROTOCOL 1000MG X 2 DOSES 2 WEEKS APART)
208-211 INFLIXIMAB RHEUMATOLOGY LOAD 2.18 208-211 INFLIXIMAB RHEUMATOLOGY LOAD 2.18 208-239 IVIG NEUROLOGY -SCHEDULE 2 DAYS MONTHLY 208-239 IVIG NEUROLOGY -SCHEDULE 2 DAYS MONTHLY
208-212 TOCILIZUMAB RHEUMATOLOGY 208-212 TOCILIZUMAB RHEUMATOLOGY 208-240 IVIG NEUROLOGY 208-240 IVIG NEUROLOGY
208-213 RITUXIMAB RHEUMATOLOGY 208-213 RITUXIMAB RHEUMATOLOGY 208-241 HYDRATIONS 208-241 HYDRATIONS
208-214 ZOLEDRONIC ACID (RECLAST) 208-214 ZOLEDRONIC ACID (RECLAST) 208-242 RECLAST RHEUMATOLOGY 208-242 RECLAST RHEUMATOLOGY
 208-215 ZOLEDRONIC ACID (ZOMETA) 208-215 ZOLEDRONIC ACID (ZOMETA) 208-243 IVIG ALLERGY 208-243 IVIG ALLERGY
208-223 OCRELIZUMAB MAINTENANCE DOSE 208-223 OCRELIZUMAB MAINTENANCE DOSE 208-244 IRON SUCROSE VENOFER (MGH) 208-244 IRON SUCROSE VENOFER (MGH)
208-224 OCRELIZUMAB LOAD DOSE (SCHEDULE WEEKS 0 2) 208-224 OCRELIZUMAB LOAD DOSE (SCHEDULE WEEKS 0 2) 208-245 PENTAMIDINE 2.18 208-245 PENTAMIDINE 2.18
 208-225 INFLIXIMAB GI MAINTENANCE 2.18 208-225 INFLIXIMAB GI MAINTENANCE 2.18  208-246 RITUXIMAB HEMATOLOGY 2.18 208-246 RITUXIMAB HEMATOLOGY 2.18
 208-226 ACCESS AND FLUSH  208-226 ACCESS AND FLUSH 208-247 RITUXIMAB NEUROLOGY 2.18 208-247 RITUXIMAB NEUROLOGY 2.18
208-227 PROLASTIN 208-227 PROLASTIN 208-248 STELARA 2.18 208-248 STELARA 2.18
208-228 SOLUMEDROL 208-228 SOLUMEDROL 208-249 TYSABRI FOR GI 2.18 208-249 TYSABRI FOR GI 2.18
208-229 VEDOLIZUMAB LOAD (SCHEDULE WEEKS 0 2 6) 208-229 VEDOLIZUMAB LOAD (SCHEDULE WEEKS 0 2 6) 208-250 TYSABRI FOR MS 2.18 208-250 TYSABRI FOR MS 2.18