AdventHealth | A Leader in Whole-Person Health Care



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Clinical Pharmacy Services

400 Celebration Place, Ste A110, Celebration, FL 34747

Phone: 407-303-4639 ( Fax: 407-303-4519

Anticoagulation Management Service Biennial Enrollment Form

|Patient Information |

|Patient name:       |DOB:       |

|Insurance information:       |Phone:       |

|Referring Physician Information |

|Physician printed name:       |NPI:       |

|Physician Phone:            |Physician Fax:       |

|Indication for Anticoagulation: |

| Afib       | Bioprosthetic mitral valve | Bioprosthetic aortic valve |

| | | |

| |Mechanical mitral valve |Mechanical aortic valve |

| DVT       | PE       | Other:       |

|Desired Anticoagulant: |

| warfarin       | dabigatran | rivaroxaban | apixaban |

|Desired INR (if warfarin is selected above) |

| 2-3 | 2.5-3.5 | Other:       |

|Anticipated Duration of Therapy |

| 3 months | Indefinite | Other: |

|Pertinent Information: |

| Renal insufficiency | History of heparin-induced thrombocytopenia (H.I.T) |

| History of major bleeding:       | History of thrombocytopenia (platelet count ................
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