Submit a Referral

Making a referral is hassle free and easy. All you have to do is submit your patient’s orders and insurance information and Pure Infusion Suites will handle the rest!

Please use the General Referral Form below for drugs not listed below:

General Order Form

Reaction Protocols (*Required for each patient order below):

Hypersensitivity Order Set

Please use this form when adding information to a previous referral.

Supplemental Order Form

Easy Referral Process


Referral form

  • Complete the appropriate referral form above
  • Attach all required insurance information, clinical notes, and labs


  • The Pure intake team works directly with insurance providers to receive pre-authorization of treatment
  • Patient Access Coordinator (PAC) will contact the patient to set expectations for the pre-authorization process that usually takes 7 business days or less

Appointment scheduling

  • After pre-authorization approval, PACs schedule an appointment with the patient and educates on infusion preparation
  • PACs will also help patients with available financial assistance programs

Infusion day

  • At Pure Infusion Suites, we are “patient obsessed!” The infusion experience includes snacks, drinks, meals, comfortable private rooms with a 55” TV, WIFI, and room for children, friends or family to keep them company


  • A nurse will follow up and check on the patient within 24 hours of their infusion
  • PACs will send the infusion notes to the provider

If you need help with your referral, please visit the location page you would like to reach and speak with our local Patient Access Coordinator (PAC).