UBACARE

has built prescriber requisition forms that are easy for you to access and download
using your tablet, laptop and even mobile device to give you flexibility while you are
on the move. Save time using our add-on prescriber order forms which are
organized by medical therapy and/or drug name in the list below.

We are committed to providing extraordinary care for your patients.

Easy Form Filling

Access our order forms and submit them online and/or fax in real-time. We tokenize and encrypt all communications to protect personal data to help us comply with data protection laws such as PIPEDA, PIPA, and CPPA.

If your therapy is not listed below, please consider electronically prescribing the medication
to us. Prescriptions must be sent from licensed prescribers and in accordance with your
Province/Territory prescribing laws.

Home Infusion Pharmacy Prescriber Order Form
Omadacycline (Nuzyra®) Prescriber Order Form
Ibalizumab-Uiyk (Trogarzo®) Prescriber Order Form

Vedolizumab (Entyvio®) Prescriber Order Form
Ustekinumab (Stelara®) Prescriber Order Form
Rituximab Prescriber Order Form
Infliximab Prescriber Order Form
Home Infusion Pharmacy Prescriber Order Form
Golimumab (Simponi Aria®) Prescriber Order Form
Certolizumab (Cimzia®) Prescriber Order Form
Abatacept (Orencia®) Prescriber Order Form

Immune Globulin – Transplant (Pediatrics) Prescriber Order Form (Peds)
Immune Globulin – Transplant (Pediatrics) Prescriber Order Form (Adult)
Immune Globulin (Pediatrics) Prescriber Order Form
Immune Globulin Maternal Fetal Medicine Prescriber Order Form
Immune Globulin (Adult) Prescriber Order Form

Home Infusion Pharmacy Prescriber Order Form
Heart Failure Infusion Services Enrollment/Order Form

Home Infusion Pharmacy Prescriber Order Form
Bleeding Disorder Enrollment Form

Hydroxyprogesterone Caproate Plan of Treatment
Home Infusion Pharmacy Prescriber Order Form

Ocrelizumab (Ocrevus®) Prescriber Order Form
Natalizumab (Tysabri®) Prescriber Order Form
Home Infusion Pharmacy Prescriber Order Form
Golodirsen (Vyondys 53®) Prescriber Order Form
Eteplirsen (Exondys 51®) Prescriber Order Form
Edaravone (Radicava®) Prescriber Order Form
Eculizumab (Soliris®) Prescriber Order Form

Ravulizumab (Ultomiristm) Prescriber Order Form
Pegloticase (Krystexxa®) Prescriber Order Form
Icatibant Prescriber Order Form
Home Infusion Pharmacy Prescriber Order Form
Ecallantide (Kalbitor®) Prescriber Order Form
C1 Esterase Inhibitor [Human] (Cinryze®) Prescriber Order Form
C1 Esterase Inhibitor [Human] (Berinert®) Prescriber Order Form