Confidentiality Notice: This fax is intended to be delivered only to the named address. It contains material that is confidential, proprietary or exempt from disclosure under applicable law. If you are not the named addressee, you should not disseminate, distribute, or copy this fax. Please notify the sender immediately if you have received this document in error and then destroy this document immediately. Faxed prescriptions will only be accepted from a prescriber. Patients must bring an original prescription to the pharmacy and cannot fax these referral forms to Watson Rx Solutions. Prescribers: By signing the attached form, you are authorizing the pharmacy and its representatives to act on your behalf to obtain prior authorizations for prescribed medication(s). We will also pursue available copay and financial assistance on behalf of your patients when available. Rev 6/2020

Diabetes Form

Phone: 833-928-7660

Fax: 833-928-7661

1106 Bradshaw Dr.

Florence, AL 35630

www.watsonrxsolutions.com

Date: ____________ Needs by Date: ____________ Ship to: Patient Doctor Other: _____________________

Patient Information

Name:_______________________________ DOB:____________________ M F SS#:____________ Street:_______________________________ City:_____________________ State:__________________ Zip:____________ Phone:______________________________ Alt Phone:________________ Wt:____________________ Ht:_____________

NKDA Allergy:___________________________________________________________________________________

Prescriber Information

Prescriber Name:__________________________________________________________________ Prescriber Type: Physician (MD or DO) Nurse Practitioner Physician’s Assistant Supervising Prescriber:______________________________________________________________ (If prescriber is a NP or PA)

Street Address: ______________________________________________ City: _______________________________ State: __________ Zip: ___________________ Phone: _______________________________ Fax: ______________________________ DEA: _______________________ NPI: _____________________ Contact Person: _________________________________________

***Please fax a copy of prescription/medical card, front and back as well as any clinical notes regarding therapy***

Medical Information

Diagnosis: ___________________________ ___________________________

New to current therapy: Yes No Hemoglobin A1C:__________ Date: _______________

Immunization History:

Influenza Date: _________________

Previous Therapies Tried and Failed (Duration): Not Tolerated: Contraindications:

_________________________ ___________________________________ ________________

_________________________ ___________________________________ ________________

_________________________ ___________________________________ ________________

_________________________ ___________________________________ ________________

_________________________ ___________________________________ ________________

Confidentiality Notice: This fax is intended to be delivered only to the named address. It contains material that is confidential, proprietary or exempt from disclosure under applicable law. If you are not the named addressee, you should not disseminate, distribute, or copy this fax. Please notify the sender immediately if you have received this document in error and then destroy this document immediately. Faxed prescriptions will only be accepted from a prescriber. Patients must bring an original prescription to the pharmacy and cannot fax these referral forms to Watson Rx Solutions. Prescribers: By signing the attached form, you are authorizing the pharmacy and its representatives to act on your behalf to obtain prior authorizations for prescribed medication(s). We will also pursue available copay and financial assistance on behalf of your patients when available. Rev 6/2020

Patient Information

Patient Name: ________________________________________ DOB: _____________ Rx Date: _________________

Prescription Information

Medication Strength Directions Quantity Refills Adlyxin 50mcg/ml 100mcg/ml Inject 10mcg subq once daily

Inject 20mcg subq once daily

Admelog 100units/mL __________________________________

Afrezza 4 unit cartridges 8 unit cartridges 12 unit cartridges

__________________________________ _____________________________________

Apdira 100units/mL Solostar Pen __________________________________

Basaglar KwikPen TempoPen __________________________________

Bydureon Bcise

2mg/0.85mL autoinjector __________________________________

Cycloset 0.8mg tablet __________________________________

Farxiga 5mg 10mg Take 1 tablet by mouth once daily

Fiasp 100 units/mL __________________________________

Humalog 100units/mL __________________________________

Invokana 100mg tablet 300mg tablet Take 1 tablet by mouth once daily

Janumet 50mg/500mg 50mg/1000mg Take 1 tablet by mouth twice daily

Janumet XR 100mg/1000mg 50mg/500mg 50mg/1000mg

Take 1 tablet by mouth once daily

Januvia 25mg 50mg 100mg Take 1 tablet by mouth once daily

Jardiance 10mg 25mg Take 1 tablet by mouth once daily

Kazano 12.5g/500mg 12.5mg/1000mg Take 1 table by mouth twice daily

Lantus 100units/mL __________________________________

Levemir 100units/mL __________________________________

Nesina 6.25mg 12.5mg 25mg Take 1 tablet by mouth once daily

Novolog 100units/mL __________________________________

Onglyza

Oseni 25mg/15mg 25mg/30mg 25mg/45mg 12.5mg/15mg 12.5mg/30mg 12.5mg/45mg

Take 1 tablet by mouth once daily Take 1 tablet by mouth twice daily __________________________________

Ozempic 0.25mg/inj 0.5mg/inj 1mg/inj

__________________________________

Rybelsus 3mg tab 7mg tab 14mg tab Take 1 tablet by mouth once daily

Segluromet 2.5mg/500mg 2.5mg/1000mg 7.5mg/500mg 7.5mg/1000mg

Take 1 tablet by mouth twice daily

Soliqua 100/33 __________________________________

Steglatro 5mg tab 15mg tab Take 1 tablet by mouth once daily

Steglujan 5mg/100mg 15mg/100mg Take 1 tablet by mouth once daily

Symlin 1.5mL pen 2.7mL pen __________________________________

Toujeo 1.5mL pen 3mL pen __________________________________

Tradjenta 5mg tab Take 1 tablet by mouth once daily

Tresiba 100units/mL pen 200units/mL pen 100 units/mL 10mL vial

__________________________________

Trulicity 0.75mg/0.5mL pen 1.5mg/0.5mL pen

Inject 0.75mg subq once weekly Inject 1.5mg subq once weekly

Victoza 6mg/mL soln __________________________________

Welchol 625mg tab 3.75gm/packet 3.75gm/bar

__________________________________

Xultophy 100/3.6 __________________________________

Other: ___________

_______________________ _____________________________________ ________ ______

Other: ___________

________________________ _____________________________________ ________ ______

____________________________________ __________ _____________________________________ __________ Dispense as Written (no stamps) Date Product Selection Permitted (no stamps) Date