Order Forms

Orders can be submitted in 3 ways:

Digital Submission

  1. Fill all necessary fields directly in Docusign.
  2. Attach all additional documentation from the checklist on page 2.
  3. Add the Provider’s e-signature to the order by:
    • Signing while filling the form, or
    • Selecting “Finish Later,” entering the provider’s email to sign and complete the order remotely.
  4. Submit the order to Pure by clicking “Finish.”

Email

  1. Fill all necessary fields by:
    • Typing directly into the order form, then download or print.
    • Download or print the order form from Docusign and fill by hand.
  2. Include all additional documentation from the checklist on page 2 and Provider’s signature.
  3. Email all documents to intake@pureinfusionsuites.com.

Fax

  1. Fill all necessary fields by:
    • Typing directly into the order form, then download or print.
    • Download or print the order form from Docusign and fill by hand.
  2. Include all additional documentation from the checklist on page 2 and Provider’s signature.
  3. Fax all documents to 1-801-931-2631.

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).

Oncology Forms

Hypersensitivity Order