This form takes about five minutes to complete. You’ll need the following information and documents for this order:
Plain Paper Form: You’ll need to print this form, fill in the instructions, and fax to us.
Fillable PDF: You can type in the required data on this form, but you’ll still have to fax to us when complete.
Use this form to order Avsola, Inflectra, Remicade, or Renflexis.If you require a different infliximab, please contact us.
