Specialist Referral Alzheimer Disease Infusion Service

Attach letter of referral here if you have one (pdf preferred)

Patient Name (required)

Patient Date of Birth (required)

Patient Address (required)

Patient Email (required)

Patient Phone number (mobile preferred)

The diagnosis is (select type a diagnosis)

—Please choose an option—Mild Cognitive Impairment (MCI)Mild Azlehimer DiseaseAlzheimer DiseaseUnsure

Reason for Referral (if no referral letter attached)
500 characters maximum.

Your name (Referring Specialist)

Your address (Referring Specialist)

Your provider number (Referring Specialist)

Your practice phone number (Referring Specialist)

My Speciality is (select type of specialist)

—Please choose an option—NeurologistGeriatricianPsychiatrist

My patient has had an MRI scan in the past 6 months

—Please choose an option—YesNo

My patient has had an FDG-PET scan in the past 2 years

—Please choose an option—YesNo

My patient has had ApoE genotyping (people with homozygous E4 do not qualify)

—Please choose an option—YesNo

I am happy to com-manage my patient during the course of treatment if they qualify for Kisunla or Leqemba (co-management is a pre-requesite)

—Please choose an option—YesNo

Please leave this field empty.