Pharmacy Inquiry Form


Please complete the following and an HoG pharmacy staff member will provide more information to you.

1.  Case Manager's Name * 
 
2.  Case Manager's Company 
 
3.  Case Manager's Title 
 
4.  Case Manager's Telephone Number * 
 

Please include area code

  
 
5.  Case Manager's Fax Number 
 
6.  Case Manager's Email Address * 
 
7.  Patient Initials 
  Please indicate the initials of the patient.  Please do not type the patient's full name.  
 
8.  Patient's Insurance Company * 
 
9.  Patient's Diagnosis * 
 
10.  Patient's Dosing Instructions * 
 

Please indicate the number of units and recommended frequency of infusion.

  
 
11.  Preferred Product * 
 

Please indicate the product or products the patient is using or would be able to use.

  
 
 
Enter the characters
as they appear in
the box to the right *  
  * Required