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FAX BACK INFUSION CONFIRMATION Please update the referring physician by faxing back this form. Date of Infusion Infusing physician comments Important Safety Information is contraindicated in patients with hypocalcemia or hypersensitivity to any component of this product. FAX REFERRAL FORM Referring physician s name 5 mg/100 mL for infusion One Infusion. Yearlong Osteoprotection. Dear Doctor/Infusion Center I am referring my patient to you for a infusion. Patient name PATIENT INFORMATION J-3488 J code SS with patient permission Patient address Patient phone Diagnosis Postmenopausal osteoporosis Paget s disease of the bone 731. 0 ICD-9 This patient has a calculated creatinine clearance of 35 mL/min and a normal serum calcium level* Yes No Date of lab results Policy Group / Policy holder Phone Secondary Insurance Primary Insurance INSURANCE 733. 01 Patient currently taking calcium and vitamin D supplements. DIAGNOSIS Date of birth Attach copies of the following Lab results Prescription Insurance card s front and back Date Physician s signature A copy of this information can be given to the patient to bring to his or her appointment. contains the same active ingredient found in acid Injection and patients receiving should not receive . All patients should be instructed on the importance of calcium and vitamin D supplementation* Please refer to full Prescribing Information for recommendations. Please see accompanying full Prescribing Information* Novartis Pharmaceuticals Corporation East Hanover NJ 07936 2008 Novartis Printed in U*S*A. 0 ICD-9 This patient has a calculated creatinine clearance of 35 mL/min and a normal serum calcium level* Yes No Date of lab results Policy Group / Policy holder Phone Secondary Insurance Primary Insurance INSURANCE 733. 01 Patient currently taking calcium and vitamin D supplements. DIAGNOSIS Date of birth Attach copies of the following Lab results Prescription Insurance card s front and back Date Physician s signature A copy of this information can be given to the patient to bring to his or her appointment. contains the same active ingredient found in acid Injection and patients receiving should not receive . All patients should be instructed on the importance of calcium and vitamin D supplementation* Please refer to full Prescribing Information for recommendations. All patients should be instructed on the importance of calcium and vitamin D supplementation* Please refer to full Prescribing Information for recommendations. Please see accompanying full Prescribing Information* Novartis Pharmaceuticals Corporation East Hanover NJ 07936 2008 Novartis Printed in U*S*A. contains the same active ingredient found in acid Injection and patients receiving should not receive . All patients should be instructed on the importance of calcium and vitamin D supplementation* Please refer to full Prescribing Information for recommendations. Please see accompanying full Prescribing Information* Novartis Pharmaceuticals Corporation East Hanover NJ 07936 2008 Novartis Printed in U*S*A.

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