Page 1 of 2 Format and content have been adapted where available with permission from M oun t Sinai H o spital RUXO Version 10 RUXO ruxolitinib Diagnosis Myelofibrosis Clinical Verification ID: 831343
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Page 1 of 2 Developed by the D
Page 1 of 2 Developed by the Drug Formulary Team at Cancer Care Ontario. Format and content have been adapted where available with permission from Mount Sinai Hospital RUXO - Version 1.0 RUXO (ruxolitinib) Diagnosis: Myelofibrosis Clinical Verification □ Bloodwork and other clinical parameters have ________ __________________ ____________________ been verified by a regulated health professional Date Print name Signature □ Prescription has been verified by an nurse or ________ __________________ ____________________ pharmacist Date Print name Signature Rx (Start date: ____________) (check appropriate dose) □ ruxolitinib 25 mg PO BID or □ ruxolitinib 20 mg* PO BID or □ ruxolitinib 15 mg* PO BID or □ ruxolitinib 10 mg* PO BID or □ ruxolitinib 5 mg* PO BID Mitte: ______ x 25 mg tablets or ______ x 20 mg tablets or _______ x 15 mg tablets or ______ x 10 mg tablets or _______ x 5 mg tablets □ EAP approved (if applicable) *Dose modification for: □ Age/performance status □ Hematologic response □ Hepatic function □ Renal function □ Other ___________________________ NO Repeats ________ _______________________ _________________________________ ______________ Date Print name Physician Signature CPSO# Prescriber information (name, office phone number/fax, address if different than hospital address) Pharmacist information (name, office phone number/fax) Hospital Information (including name, address, telephone number) Clinic information (including clinic name and telephone number) Patient information (including name, address, date of birth, phone number) Patient Name _________________________________________ Allergies (also specify reaction) □ None known Page 2 of 2 Developed by the Drug Formulary Team at Cancer Care Ontario. Format and content have been adapted where available with permission from Mount Sinai Hospital RUXO - Version 1.0 OPTIONAL INFORMATION □ Patient has been counseled by an Oncology Pharmacist ____________________ ________________________________ _______________ Print name Signature Date OR □ Requires counseling □ Drug interac
tion assessment Drug-specific in
tion assessment Drug-specific information For the complete information, please refer to the Cancer Care Ontario drug information sheets available at www.cancercare.on.ca/drugformulary ��Page of Developed by the Drug Formulary Team at Cancer Care Ontario. Format and content have been adapted with permission from Mount Sinai Hospital RUXO - Version 1.0 OPTIONAL INFORMATION Patient has been counseled by an Oncology Pharmacist____________________Print name Signature Date Requires counselingDrug interaction assessmentDrug-specific information For the complete information, please refer to the Cancer Care Ontario drug information sheets available at www.cancercare.on.ca/drugformulary ��Page of Developed by the Drug Formulary Team at Cancer Care Ontario. Format and content have been adapted with permission from Mount Sinai Hospital RUXO - Version 1.0 RUXO (ruxolitinib) Diagnosis: Myelofibrosis Clinical Verification Bloodwork and other clinical parameters have________ __________________ ____________________ been verified by a regulated health professional Date Print name Signature Prescription has been verified by an nurse or________ __________________ ____________________ pharmacist Date Print name Signature Rx (Start date: ____________) (check appropriate dose) ruxolitinib 25 mg PO BID orruxolitinib 20 mg* PO BID orruxolitinib 15 mg* PO BID orruxolitinib 10 mg* PO BID orruxolitinib 5 mg* PO BID Mitte: ______ x 25 mg tablets or ______ x 20 mg tablets or _______ x 15 mg tablets or ______ x 10 mg tablets or _______ x 5 mg tablets □EAP approved (if applicable)*Dose modification for: □ Age/performance status □ Hematologic response □ Hepatic function □ Renal function□Other ___________________________NO Repeats ________ _______________________ _________________________________ ______________ Date Print name Physician Signature CPSO# Prescriber information (name, office phone number/fax, address if different than hospital address) Pharmacist information (name, office phone number/fax) Hospital Information (including name, address, telephone number) Clinic information (including clinic name and telephone number) Patient information (including name, address, date of birth, phone number) Patient Name _________________________________________ Allergies (also specify reaction) 一漀渀攀 欀渀漀眀渀