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Copyright © 2017 by Diplomat Pharmacy Inc. All rights reserved. Diplomat is a registered trademark of Diplomat Pharmacy Inc. 04242017

Patient Name: ________________________________ DOB: _____________ Sex: Female Male SSN: ______________________________________ Language: ________________ Wt:______ kg lbs Ht:______ cm in Address: ______________________________________________________ Apt/Suite: ________ City:____________________ State:______ Zip:______ Phone:____________________ Alternate Phone:______________________ Caregiver name: _________________________ Relation: _______________ Local Pharmacy: _________________________ Phone: ________________

Prescriber Name:_______________________________________________ NPI: _______________________________________________________ Address: _____________________________________________________ Apt/Suite: _______ City:____________________ State:______ Zip:______ Contact: ______________________________________________________ Phone: ________________________ Alternate: ______________________ Fax: _________________________________________________________ Email address: ________________________________________________ If shipping to presciber: First Fill Always Never

Insurance Information (Please fax a copy of front and back of the insurance cards) 1˚ Insurance Plan: _____________________ Plan ID # ___________________ Policy Holder: ___________________________ Relation: ______________ 2˚ Insurance Plan: _____________________ Plan ID # ___________________ Policy Holder: ___________________________ Relation: ______________

Clinical Information (Please fax all pertinent clinical and lab information) Diagnosis: E88.01 (Alpha-1 Antitrypsin Deficiency) _______________________________________________________________________

Date of Diagnosis: _______________________________________________ Access: Peripheral Implanted Port Other: ______________________

Has patient been treated with these products previously? Yes No If yes, product information: _______________________________________ Date of last infusion: ____________ Date of next infusion: ______________

Comorbidities: __________________________________________________________________________________________________________________Concomitant Medications: _________________________________________________________________________________________________________Allergies: NKDA Other: _____________________________________________________________________________________________________ Prescription

Pre-Medications and Pre-Protocol

Anaphylaxis Orders and Medications

Ancillary Supplies Supplies as needed for administration and appropriate disposal of infusion materials.

Skilled Nursing Visits As needed for IV access, administration and appropriate clinical monitoring.

Administration procedures to be followed per pharmacy protocol.

Per state-specific law, prescriptions will be dispensed as generic, if applicable, unless notated otherwise: __________________________________________

Prescriber’s Signature:__________________________________________________________________________________ Date: _________________ I authorize Diplomat Pharmacy, Inc. and its representatives to act as an agent to initiate and execute the insurance prior authorization process for this prescription and any

future fills of the same prescription for the patient listed above. I understand that I can revoke this designation at any time by providing written notice to Diplomat Pharmacy, Inc.

Alpha-1 Antitrypsin DeficiencyPatient Information

Serum AAT Level:______________ mg/dL Date: ______________ PFT: FEV1 % predicted:_______________________ Date: ______________ CXR/CT results:_____________________________ Date: ______________ Phenotype: PiZZ PiSZ PiMZ Other:__________________________

Aralast™ NP Glassia® Zemaira®Alpha-1 Antitrypsin Deficiency Products

Therapy Regimen Dose: 60 mg/kg OR ____________ mg/kg Total dose: ____________________ mg Directions: Infuse once every week for __________ weeks ________________________________________ Refills: __________________ Quantity to Dispense: _________________________________________________ Administration Rate: Per manufacture guidelines, as tolerated _____________________________________

Orders: 2. Call 911 and prescribing physician3. Administer medications below as per protocol

Diphenhydramine 50 mg/mL

Quantity: 1 x 50 mg vial

Epinephrine 1 mg/mL

Quantity: 2 vials

Sodium Chloride 0.9% Use as directed per protocol Quantity: 1 x 500 mL Bag

The quantity and refills for the flushing protocol medications will match the Alpha-1 Antitrypsin deficiency therapy administration requirements.

Administer 12.5 mg/0.25 mL (weight <15 kg) by slow IV push or IM Administer 25 mg/0.5 mL (weight 15-30 kg) by slow IV push or IM Administer 50 mg/mL (weight >30 kg) by slow IV push or IM

Administer ____ mg (0.01 mg/kg or 0.01mL/kg) (weight <15 kg) IM Administer 0.15 mg/0.15 mL (weight 15-30 kg) IM Administer 0.3 mg/0.3mL (weight >30 kg) IM

1. Stop infusion

Refills

Pre-medication:_____________________________________________________________________________________

Directions: _________________________________________________________________________________________

Quantity: __________________________________________________________________________________________

Refills: ____________________________________________________________________________________________

Flushing Per Protocol Sodium Chloride 0.9% 5-10 mL pre and post medications Heparin 100 units/mL as needed