Infusion Services Forms

Submit the form directly to First Choice staff

We offer our forms free for use to submit referrals directly to First Choice staff for review. Please select the needed form from the list below, fill it out either electronically or by hand, and then send the form and all requested patient information to us via email (infusions@firstchoiceiv.com) or fax (1-844-461-3244).

If you have your own forms or prescriptions, please free to use those and email (infusions@firstchoiceiv.com) or fax (1-844-461-3244).

Below is a list of enrollment forms for an array of conditions and diseases that First Choice Wellness & Infusion Centers can assist with treatment and medications. If there is a condition/medication not listed and are in need of a standard enrollment form, please contact us and we will be glad to develop one for your use. We also have an All Other Infusions Form available for any treatment not listed.

A
  • Actemra
  • Adbry
  • Amvuttra
  • B
  • Benlysta
  • C
  • Cinqair
  • Cinryze
  • Cimzia
  • E
  • Entyvio
  • Evkeeza
  • I
  • Ilaris – AOSD, SJIA
  • Ilaris – CAPS
  • Ilaris – TRAPS, HIDS/MKD, FMF
  • Inflectra
  • IVIG
  • K
  • Krystexxa
  • L
  • Lemtrada
  • Leqvio
  • N
  • Nucala
  • O
  • Ocrevus
  • Onpattro
  • Orencia
  • P
  • Procrit
  • Prolia
  • R
  • Remicade
  • Renflexis
  • Rituxan
  • S
  • Saphnelo
  • Simponi Aria
  • Soliris
  • Soliris (Under 18)
  • Stelara
  • T
  • Tepezza
  • Tezspire
  • Tysabri
  • U
  • Ultomiris
  • Uplizna
  • V
  • Vyepti
  • Vyvgart
  • X
  • Xolair