FORTEO RX
FORM
www.BellavidaPharmacy.com
PATIENT INFORMATION
Patient Name:
Male
Date of Birth:
SSN:
PRESCRIBER INFORMATION
Female
Address:
DEA:
Address:
City, State, Zip Code:
City, State, Zip Code
Phone:
Prescriber Name:
Phone
Contact Person:
INSURANCE INFORMATION
Please fax a copy (front and back) of patients current
active Insurance and ID cards.
Date:
NPI
Need Date:
Fax:
Weight : _________
CLIENT INFO
Height:_____________
CLINICAL INFORMATION - Please provide most recent lab reports
Diagnosis:
Senile Osteoporosis M81.0_______
Osteoporosis M81.8 _________
Fracture History __________Location:
T- Score_________________Other Risk Factors:
History of Prior Therapy
Fosamax
Actonel
Miacacin NS
Alendronate
Boniva
Atelvia
Reclast
Steroids
Other ________
Reason for discontinuing previous therapy:
Contraindications:
Other patient medical information (such as supplements {list}):
MEDICATION
STRENGTH
600 mcg / 2.4 mL PFS
FORTEO
Pen Needles
Alcohol Swabs
Other
31 Gauge 5 mm
SIG / DIRECTIONS
Inject 20 mcg SQ QD
Use daily as directed with Forteo
Use daily as directed with Forteo
QTY
2.4 ml
REFILLS
100
100
Prescription Information
By singing below, the prescriber gives consent to both, the prescription(s) above, as well as to Bella
Vida Pharmacy to act as the prescriber's agent to begin and execute the prior authorization process
and to help the patient apply to co-pay assistance programs, including all foundations and
manufacturer assistance programs if necessary.
Prescriber Signature: ________________________ Date: ________________
email us: [email protected]
1039 West Carson Street
Torrance, CA 90502
Phone: 310-320-3333
Fax: 310-320-3334