Pure Infusion Suites Online Referral Form Pilot

At Pure Infusion Suites, we are always looking for ways to improve the referral process for our partners as well as expedite the preauthorization process to see your patients faster. We are testing out an online referral form that will help in both of those areas. We would love your feedback and insight as we look to implement a shift in how we receive referrals.

  1. Select the appropriate medication form below.
  2. Fill out each of the following sections on the secure, online referral form. Note that anything with a red * is a required field.
    • Patient Information
    • Lab Work
      • Remember to attach all necessary documentation to expedite the preauthorization process.
    • Dosing
    • Prescribing Provider Information
  3. Click “Submit Referral”
    • Once submitted, you will receive a confirmation email.
    • Your patient will then be contacted within 24 hours.
Supplemental Order Form
General Order Form
Actemra Referral Form
Aduhelm Referral Form
Avsola Referral Form
Benlysta Referral Form
Cerezyme Referral Form
Cimzia Referral Form
Cinqair Referral Form
Entyvio Referral Form
Evenity Referral Form
Fasenra Referral Form
Feraheme Referral Form
Ferrlecit Referral Form
Givlaari Referral Form
Glassia Referral Form
IVIG Referral Form
Ilaris Referral Form
Ilumya Referral Form
Inflectra Referral Form
Injectafer Referral Form
Kalbitor Referral Form
Krystexxa Referral Form
Lab Order Form
Lemtrada Referral Form
Leqvio Referral Form
Nucala Referral Form
Nulojix Referral Form
Ocrevus Referral Form
Orbactiv Referral Form
Orencia Referral Form
Port Flush Order Form
Prolastin C Referral Form
Prolia Referral Form
Radicava Referral Form
Remicade Referral Form
Renflexis Referral Form
Rituxan Referral Form
Ruxience Referral Form
Simponi Aria Referral Form
Skyrizi Referral Form
Soliris Referral Form
Solumedrol/Methylprednisolone Referral Form
Stelara Referral Form
Steroid Referral Form
Tepezza Referral Form
Truxima Referral Form
Tysabri Referral Form
Ultomiris Referral Form
Venofer Referral Form
Vyepti Referral Form
Vyvgart Referral Form
Xolair Referral Form
Zinplava Referral Form
Zoledronic Acid Referral Form