IMPORTANT NOTICE: This facsimile transmission is intended to be delivered only to the named addressee and may contain material that is confidential, privileged, proprietary or exempt from disclosure under applicable law. If it is received by anyoneother than the named addressee, the recipient should immediately notify the sender at the address and telephone number set forth herein and obtain instructions as to disposal of the transmitted material. In no event should such material be read orretained by anyone other than the named addressee, except by express authority of the sender to the named addressee.

X X

Dermatology Enrollment Form Phone: 602-971-6950 / 877-971-3001 Fax: 877-552-5698

PATIENT INFORMATION PRESCRIBER INFORMATION (Complete the following or include demographic sheet) Prescriber’s Name:

Patient Name: State License #: NPI #: Address: DEA #:

City, State, Zip: Group or Hospital: Primary Phone: DOB: Address:

Alternate Phone: Gender: Male Female City, State Zip:

Last 4 digits of SS#: Phone: Fax:

Primary Language: Contact Person: Phone:

PRESCRIPTION INFORMATION

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Vasco Rx Pharmacy can accept only original prescription drug orders from patients, and faxed prescriptions from the prescribing practitioners.

Drug Directions and Quantity Refills

Enbrel®

Sensoready Pen

Pre-filled Syringe

INNNITIAAAL: Inject 300 mg SQ on week 0, 1, 2, 3 and 4 (Quantity: 10)MAAAINNNTEEENNNAAANNNCCCEEE: Inject 300 mg SQ every 4 weeks (Quantity: 2)INNNITIAAAL: Inject 150 mg SQ on week 0, 1, 2, 3 and 4 (Quantity: 5)MAAAINNNTEEENNNAAANNNCCCEEE: Inject 150 mg SQ every 4 weeks (Quantity: 1)

Humira®

Simponi®

SureClick Pen 50mg

Pre-filled Syringe

25mg 50mg

Vials 25mg

Otezla®

New Refill Ship by: ____/____/____ SHIP TO: Patient’s Home Doctor’s Office Other ___________________

Cosentyx®

DATE

Inject 50 mg SQ twice weekly 72-96 hours apart (Quantity: 8) Inject 50 mg SQ every week (Quantity: 4) Inject 25 mg SQ twice weekly 72-96 hours apart (Quantity: 8)

PPPsoriasis Initial: Inject 50 mg SQ twice weekly (72-96 hours apart) for 3 months (QTY: 8 with 2 refills)

Psoriasis Maintenance: Inject 50 mg SQ weekly (Quantity: 4)

Psoriasis Starter Kit

Pen Pre-filled Syringe

HS Starter Kit

Pen Pre-filled Syringe

INNNITIAAAL: Inject 80 mg SQ on day 1, 40 mg on day 8, then 40 mg every other week (Quantity: 4)MAAAINNNTEEENNNAAANNNCCCEEE: Inject 40 mg SQ every other week (Quantity: 2)

INNNITIAAAL: Inject 160 mg SQ on day 1, then 80 mg on day 15 (Quantity: 6)MAAAINNNTEEENNNAAANNNCCCEEE: Inject 40 mg SQ every week (Quantity: 4)

Take as directed per package instructions (Quantity: 55)14 day titration starter pack sample provided by MD office

Take 30 mg PO twice daily (Quantity: 60) Take 30 mg PO once daily (Quantity: 30) CCContinuation offf Therapy: Yes No

Take 30 mg PO twice daily (Quantity: 28) (12 refills) Take 30 mg PO once daily (Quantity: 28) (6 refills)

28 Day Starter Pack

Maintenance

Bridge Dose Pack

SmartJect® Pen

Pre-filled SyringeInject 50 mg SQ once monthly (Quantity: 1)

Stelara®

INNNITIAAAL: Inject 45 mg SQ on day 0 and day 28 (Quantity: 2)MAAAINNNTEEENNNAAANNNCCCEEE: Inject 45 mg SQ every 12 weeks (Quantity: 1)

INNNITIAAAL: Inject 90 mg SQ on day 0 and on day 28 (Quantity: 2) **WWWeight mmmust be greater thanMAAAINNNTEEENNNAAANNNCCCEEE: Inject 90 mg SQ every 12 weeks (Quantity: 1) or equal to 222222000lbs

Pre-filled Syringe

Weight Required: ______

Taltz® Auto Injector

Pre-filled Syringe

STAAARTINNNG: Inject 160 mg SQ on week 0 (Quantity: 2)INNNDUCCCTIONNN: Inject 80 mg SQ every 2 weeks (weeks 2-12) (Quantity: 2 plus 2 refills)

MAAAINNNTEEENNNAAANNNCCCEEE: Inject 80 mg SQ every 4 weeks (after 12 weeks) (Quantity: 1)

American Academy of Dermatology Consensus Statement on Psoriasis TherapiesPsoriasis is covering greater than 10% of body surface area Psoriasis is on palms, soles, head and neck, or genitalia Psoriasis occurs in conjunction with pain, swelling, or stiffness in joints Psoriasis patient needs more aggressive therapy due to impact on ability to perform daily activities, employment, or interpersonal relationship.

INJECTION TRAININGPatients has received pen and injection training Physician’s office to provide injection training Vasco Rx to coordinate injection training

Prescribing Practitioner

To Prescribing Practitioner: By signing this form and utilizing our services, you are also authorizing Vasco Rx to serve as your prior authorization designated agent in dealing with medical and prescription insurance companies, and co-pay assistance foundations.

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Phone: 602-971-6950 / 877-971-3001 Fax: 877-552-5698

PATIENT INFORMATION PRESCRIBER INFORMATION (Complete the following or include demographic sheet) Prescriber’s Name:

Patient Name: State License #: NPI #: Address: DEA #:

City, State, Zip: Group or Hospital: Primary Phone: DOB: Address:

Alternate Phone: Gender: Male Female City, State Zip:

Last 4 digits of SS#: Phone: Fax:

Primary Language: Contact Person: Phone:

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Vasco Rx Pharmacy can accept only original prescription drug orders from patients, and faxed prescriptions from the prescribing practitioners.

MEDICAL INFORMATION

***PLEASE FAX COPY OF PRESCRIPTION/MEDICAL CARD, FRONT AND BACK, AS WELL AS ANY CLINICAL NOTES REGARDING THERAPY***

DMARDS: Tried & Failed (Duration):Methotrexate

Soriatane

Cyclosporine

( )

( )

( )

( )

Not Tolerated: Contraindication:

TOPICAL Agents:

Clobetasol

Hydrocortisone

Contraindication:

PHOTOTHERAPY

UVA/ UVB

Patient cannot afford Photosensitivity Risk of Skin Cancer Distance from Office

Tried & Failed (Duration):( )

Not Tolerated: Contraindication:

SPECIALTY Drugs:Enbrel

Humira

Tried & Failed (Duration):( )

( )

( )

Not Tolerated: Contraindication:

Affected Areas

Hands Feet ScalpGroin Nails FaceOther:BSA (% is required): ______%

Date of Diagnosis:

____/____/____

L40.0 Psoriasis Vulgaris (Plaque Psoriasis)

L40.50 Arthropathic Psoriasis, Unspecified (Include failed

NSAIDs: )

L73.2 Hidradenitis suppurativa

Other:

Active TB is ruled out: Yes No Date: ___/___/___

Hep B ruled out/treated: Yes No Date: ___/___/___

Allergies:

Additional Clinical Information:

Tried & Failed (Duration):( )

( )

( )

Not Tolerated:

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