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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