Get the free AZ Caprelsa Referral Form

CAPELLA (vandetanib) Prescription Form Specialty Pharmacy Partner CERTIFICATION REQUIRED PRESCRIBE CAPELLA: VISIT www.caprelsarems.com for information TO Fax: 800.823.4506 Phone: 800.850.4306 PATIENT

How to fill out az caprelsa referral form

How to fill out AZ Caprelsa referral form:

1. Start by obtaining the AZ Caprelsa referral form from your healthcare provider or the appropriate medical facility.
2. Fill out your personal information accurately, including your full name, date of birth, address, and contact details.
3. Provide your medical history and any relevant medical conditions or medications you are currently taking.
4. Include information about your healthcare provider, such as their name, address, and contact details.
5. Indicate the reason for the referral, including the specific condition or symptoms that require Az Caprelsa treatment.
6. Include any supporting documentation or test results that may be necessary for the referral, such as MRI scans or lab reports.
7. Review the completed form to ensure all the information is accurate and complete.
8. Sign and date the referral form, confirming your consent and understanding of the information provided.
9. Submit the referral form to your healthcare provider or the appropriate medical facility, following their specific instructions for submission.

Who needs AZ Caprelsa referral form:

1. Patients who have been diagnosed with a specific medical condition that may benefit from AZ Caprelsa treatment.
2. Individuals who have been recommended by their healthcare provider to undergo AZ Caprelsa therapy.
3. Patients who are seeking specialized medical care or consultation related to their condition, and require a referral to access AZ Caprelsa treatment.

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