Healthcare Linagliptin Prescription Form

Healthcare Linagliptin Prescription Form

Patient Information

Patient Name:

Date of Birth:    Gender:

Insurance Information

Medical History & Clinical Information

Chronic Conditions (select all applicable):
Type 2 Diabetes Type 1 Diabetes Renal Impairment Hepatic Impairment Heart Failure

Pregnant or breastfeeding: Pregnant Breastfeeding

Prescription Details

Medication: Linagliptin (brand/generic):

Route:    Quantity:    Refills:    Days Supply:

ICD-10 Diagnosis Code:

Substitution: Allow generic substitution    Dispense As Written (DAW): DAW

Prior Authorization Required: Yes No

Prescriber Information (for pharmacy/records)

Warnings, Contraindications and Administrative Notices

Linagliptin is indicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus. Prescriber attests that this prescription is being issued for a legitimate medical purpose in the usual course of professional practice. The prescriber has reviewed the patient's medical history and medication list for potential contraindications and interactions.

Important safety information — patient and pharmacist should review prior to dispensing: Linagliptin may increase the risk of hypoglycemia when used in combination with insulin or insulin secretagogues such as sulfonylureas; monitor blood glucose and adjust concomitant therapy as indicated. Discontinue and evaluate for pancreatitis if persistent severe abdominal pain occurs. Severe hypersensitivity reactions, including anaphylaxis and angioedema, have been reported; discontinue if suspected. Use caution in patients with a history of pancreatitis, severe renal or hepatic impairment, or heart failure; individualize therapy.

The prescriber has considered the patient's renal and hepatic function, pregnancy and lactation status, and other comorbidities. The patient is advised to report adverse events and to seek medical attention for signs of hypoglycemia, pancreatitis, or severe allergic reaction.

Patient Acknowledgment & Authorization

By signing below, I confirm that I have provided accurate medical history and medication information, understand the intended benefits, common side effects, and serious warnings associated with linagliptin, and have had the opportunity to ask questions. I authorize the release of my medical information to the pharmacy and insurer for the purpose of dispensing and reimbursement of this prescription.

Authorization Expiration Date:

HIPAA Acknowledgement: I acknowledge the privacy practices and consent to release protected health information as necessary for treatment, payment and healthcare operations.

Sign Now