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Home For Medical Professionals Refer a Patient Online Medication Referral Form

Refer a Patient

Refer a Patient for Non-Oncology Infusion Services

If you are a physician or provider who wants to refer a patient for non-oncology infusion, use the following information.

Epic Providers

For providers using Epic, use referral code REF144- Ambulatory Referral to Infusion Services; Department Name: BAPT OP Infusion SVCS.

More information for Epic users.

Providers Not Using Epic

Find the condition you are treating below and use the associated referral form linked there.

For general questions, call us at 901-752-6131.

Baptist Cancer Center does not provide infusion services for patients under the age of 18.

Alzheimer's

Complete this referral form to order the following medications.

Donanemab (Kisunla)
Lecanemab (Leqembi)

Bone Health

Complete this referral form to order the following medications.

Burosumab (Crysvita)
Denosumab (Prolia)
Romosozumab (Evenity)
Zoledronic Acid (Reclast)

Cardiology

Complete this referral form to order the following medications.

Inclisiran (Leqvio)
Patisiran (Onpattro)
Vutrisiran (Amvuttra)

Endocrine

Complete this referral form to order the following medications.

Belatacept (Nulojix)
Burosumab (Crysvita)
Romosozumab (Evenity)
Teplizumab (Tzield)
Teprotumumab (Tepezza)
Thyrotropin Alfa (Thyrogen)
Zoledronic Acid (Reclast)
Zoledronic Acid (Zometa)

Gastrointestinal

Complete this referral form to order the following medications.

Certolizumab (Cimzia)
Guselkumab (Tremfya)
Infliximab (Remicade/biosimilars)
Mirikizumab (Omvoh)
Natalizumab (Tysabri)
Ustekinumab (Stelara)
Vedolizumab (Entyvio)

Headache

Complete this referral form to order the following medications.

Caffeine Na Benzoate
Dexamethasone (Decadron)
Diphenhydramine (Benadryl)
Eptinezumab (Vyepti)
Ketorolac (Toradol)
Ketorolac (Toradol)
Magnesium Sulfate
Methocarbamol (Robaxin)
Methylprednisolone (Solu-Medrol)
Prochlorperazine (Compazine)
Sodium Chloride 0.9% (NS)
Valproic Acid (Depacon)

Infectious Disease

Complete this referral form to order the following medications.

Ampicillin (Omnipen)
Cabotegravir (Cabenuva)
Cabotegravir (Cabenuva)
Cabotegravir (Cabenuva)
Cabotegravir (Cabenuva)
Cefazolin (Ancef)
Ceftriaxone (Rocephin)
Dalbavancin (Dalvance)
Daptomycin (Cubicin)
Eravacycline (Xerava)
Fecal Microbiota (Rebyota)
Foscarnet (Foscavir)
Ibalizumab (Trogarzo)

Hematologic/Renal

Complete this referral form to order the following medications.

Darbepoetin (Aranesp)
Epoetin Alfa
Ferric Carboxymaltose (Injectafer)
Ferric Carboxymaltose (Injectafer)
Ferric Derisomaltose (Monoferric)
Iron Sucrose (Venofer)
Romiplostim (Nplate)
Sutimlimab (Enjaymo)

IV Iron

Complete this referral form to order the following medications.

Ferric Carboxymaltose (Injecatafer)
Ferric Derisomaltose (Monoferric)
Iron Sucrose (Venofer)

Neurology

Complete this referral form to order the following medications.

Edaravone (Radicava)
Efgartigimod alfa (Vyvgart)
Eptinezumab (Vyepti)
Inebilizumab (Uplizna)
Ocrelizumab SQ (Ocrevus Zunovo)
Ocrelizumab IV (Ocrevus)
Rozanolixizumab (Rystiggo)
Tocilizumab (Actemra)

Pulmonology

Complete this referral form to order the following medications.

Alpha-1 Proteinase (Glassia, Prolastin-C, Zemaira)
Benralizumab (Fasenra)
Mepolizumab (Nucala)
Omalizumab (Xolair)
Reslizumab (Cinqair)
Tezepelumab (Tezspire)

Rheumatology

Complete this referral form to order the following medications.

Abatacept (Orencia)
Anifrolumab (Saphnelo)
Belimumab (Benlysta)
Certolizumab (Cimzia)
Golimumab (Simponi Aria)
IVIG
Infliximab (Remicade/Biosimliars)
Natalizumab (Tysabri)
Pegloticase (Krystexxa)
Risankizumab (Skyrizi)
Rituximab (Rituxan/Biosimilars)
Secukinumab (Cosentyx)
Tocilizumab (Actemra)
Ustekinumab (Stelara)

Other

Complete this referral form to order the following medications.

Belatacept (Nulojix)
Cabtegravir (Cabenuva)
Evinacumab (Evkeeza)
Teprotumumab (Tepezza)
Tildrakizumab (Ilumya)