Conditions We Treat

Please click here to contact us if you do not see your condition listed:

  • Gout

  • Heterozygous familial hypercholesterolemia (HeFH)

  • High cholesterol

  • Hypogammaglobulinemia alpha-1 antitrypsin (AAT) deficiency

  • Idiopathic thrombocytopenic purpura (ITP)

  • Iron deficiency

  • Juvenile idiopathic arthritis (JIA)

  • Lupus

  • Migraines

  • Multiple sclerosis

  • Alzheimer’s disease​

  • Allergic asthma

  • Amyotrphic lateral sclerosis

  • Anemia

  • Ankylosing spondylitis

  • Asthma

  • Atherosclerotic cardiovascular disease (ASCVD)

  • Chronic inflammatory demyelinating polyneuropathy (CIDP)

  • Crohn’s disease

  • Gaucher disease

Infusion Treatments

Efficient Referral Process

  • Click the “Submit a Referral” button to view our list of convenient fillable PDF referral forms. Click the appropriate treatment and fill out the form - two easy ways to submit once downloaded:

    A) Print, complete, and fax

    OR

    B) Complete by typing into the form fields on the computer and email/fax

    Please be sure to attach all clinical notes, labs, and insurance information.

    hello@flourishhealth.com
    Fax: (219) 319-5121

  • We work directly with insurance providers to receive treatment pre-authorization.

    We will contact the patient to set expectations for the pre-authorization process that typically takes 5-7 business days.

  • Post pre-authorization approval, we will contact the patient to share infusion information and schedule an appointment.

    We will also assist with any available financial assistance programs.

  • Our expert medical staff administers infusions while pampering the patients in our relaxing, comfortable, spa-like atmosphere.

  • Our nurses will check on the patient within the first 24 hours of the infusion.

    Expect precise, prompt communication with your practice including detailed patient reports following every infusion.

Submit a Referral

Flourish Referral Forms

We have made referrals for medical infusion treatments easy and convenient for our referring providers.

Simply click the specific treatment or general form and fill it out. Please print, complete, and fax the forms to the appropriate location (see below).

Please be sure to attach all clinical notes, labs, and insurance information.

Email: hello@flourishhealth.com

South Bend Location
305 W University Dr.
Mishawaka, IN 46545
Tel: 855-553-2273
Fax: 574-666-2888

Dyer Location
1160 Joliet St.
Suite 204
Dyer, IN 46311
Tel: 800-799-2273
Fax: 219-319-5121

Fort Wayne Location
7403 Coldwater Rd.
Fort Wayne, IN 46825
Tel: 725-272-2273
Fax: 725-272-2273

Hobart Location
8081 Randolph St.
Suite A
Hobart, IN 46342
Tel: 800-799-2273
Fax: 219-319-5121

General Form

  • Download Actemra form here.

    Required clinicals:

    • Negative TB screen

    • Demographics

    • Labs & Tests Supporting Diagnoses

    • Office/Progress Notes

  • Download Benlysta order form here.

    Required clinicals:

    • Demographics

    • Labs & Tests Supporting Diagnoses

    • Office/Progress Notes

  • Download Briumvi order form here.

    Required clinicals:

    • Negative Hep B

    • Demographics

    • Labs & Tests Supporting Diagnoses

    • Office/Progress Notes

    • Baseline liver function tests (LFTs) (ALT, AST, bilirubin, alkaline phosphatase) within 6 months

  • Download Cabenuva order form here.

    Required clinicals:

    • Demographics

    • Labs & Tests Supporting Diagnoses

    • Office/Progress Notes

  • Download Entyvio order form here.

    Required clinicals:

    • Negative TB results

    • Demographics

    • Labs & Tests Supporting Diagnoses 

    • Office/Progress Notes

  • Download Evenity order form here.

    Required clinicals:

    • Normal calcium within 6 months of referral 

    • Demographics

    • Labs & Tests Supporting Diagnoses 

    • Office/Progress Notes

  • Download Fasenra order form here.

    Required clinicals:

    • Demographics

    • Labs & Tests Supporting Diagnoses 

    • Office/Progress Notes

  • Download Hyqvia order form here.

    Required clinicals:

    • Demographics

    • Labs & Tests Supporting Diagnoses 

    • Office/Progress Notes

  • Download Ilumya order form here.

    Required clinicals:

    • Negative TB

    • Demographics

    • Labs & Tests Supporting Diagnoses 

    • Office/Progress Notes

  • Download the iron order form here.

  • Download Kisunla order form here.

    Required clinicals:

    • Baseline MRI within 1 year, with repeat MRIs needed prior to the 2nd, 3rd, 4th, and 7th infusion

    • Demographics

    • Labs & Tests Supporting Diagnoses 

    • Office/Progress Notes

  • Download Krystexxa order form here.

    Required clinicals:

    • G6PD results

    • Serum uric acid level within 1 month for initiation of therapy, within 48 hours for ongoing treatments

    • Documentation of initiation of Methotrexate and folic acid

    • Demographics

    • Labs & Tests Supporting Diagnoses 

    • Office/Progress Notes

  • Download Leqembi order form here.

    Required clinicals:

    • Baseline MRI within 1 year

    • Repeat MRIs needed prior to the 3rd, 5th, 7th and 14th infusion (more frequently if ARIA suspected)

    • Demographics

    • Labs & Tests Supporting Diagnoses

    • Office/Progress Notes

  • Download Leqvio order form here.

    Required clinicals:

  • Download Nucala order form here.

    Required clinicals:

    • Demographics

    • Labs & Tests Supporting Diagnoses 

    • Office/Progress Notes

  • Download Ocrevus order form here.

    Required clinicals:

    • Negative Hep B

    • Demographics

    • Labs & Tests Supporting Diagnoses 

    • Office/Progress Notes

    • Baseline liver function tests (LFTs) (ALT, AST, bilirubin, alkaline phosphatase) within 6 months

  • Download Ocrevus Zunovo form here.

    Required clinicals:

    • Negative Hep B

    • Demographics

    • Labs & Tests Supporting Diagnoses 

    • Office/Progress Notes

    • Baseline liver function tests (LFTs) (ALT, AST, bilirubin, alkaline phosphatase) within 6 months

  • Download Omvoh form here.

    Required clinicals:

    • Negative TB test

    • Demographics

    • Labs & Tests Supporting Diagnoses 

    • Office/Progress Notes

  • Download Onpattro order form here.

    Required clinicals:

    • Demographics

    • Labs & Tests Supporting Diagnoses 

    • Office/Progress Notes

  • Download Orencia order form here.

    Required clinicals: 

    • Negative TB 

    • Negative Hep B 

    • Demographics

    • Labs & Tests Supporting Diagnoses 

    • Office/Progress Notes 

  • Download Prolia & Biosimilar order form here

    Required clinicals:

    • Normal calcium within 6 months of referral

    • Demographics

    • Labs & Tests Supporting Diagnoses 

    • Office/Progress Notes

  • Download Remicade & Biosimilars order form here.

    Required clinicals: 

    • Negative TB

    • Negative Hep B results

    • Demographics

    • Labs & Tests Supporting Diagnoses 

    • Office/Progress Notes

  • Download Rituxan & Biosimilars order form here.

    Required clinicals: 

    • ​​​​Negative Hep B

    • Demographics

    • Labs & Tests Supporting Diagnoses 

    • Office/Progress Notes

  • Download Saphnelo order form here.

    Required clinicals:

    • Demographics

    • Labs & Tests Supporting Diagnoses 

    • Office/Progress Notes

  • Download Simponi Aria order form here.

    Required clinicals: 

    • Negative TB 

    • Negative Hep B

    • Demographics

    • Labs & Tests Supporting Diagnoses 

    • Office/Progress Notes

  • Download Skyrizi order form here.

    Required clinicals: 

    • Negative TB screening

    • Demographics

    • Labs & Tests Supporting Diagnoses 

    • Office/Progress Notes

  • Download Soliris order form here.

    Required clinicals: 

    • Documentation of meningitis vaccine (at least 2 weeks before 1st infusion)

    • Demographics

    • Labs & Tests Supporting Diagnoses 

    • Office/Progress Notes

  • Download Stelara & Biosimilars order forms here:

    Required clinicals: 

    • Negative TB

    • Demographics

    • Labs & Tests Supporting Diagnoses 

    • Office/Progress Notes

  • Download Tepezza order form here.

    Required clinicals: 

    • Thyroid panel within 6 months of referral prior to initiation of therapy

    • Hearing test completed prior to treatment

    • Demographics

    • Labs & Tests Supporting Diagnoses 

    • Office/Progress Notes

  • Download Tezspire order form here.

    Required clinicals:

    • Demographics

    • Labs & Tests Supporting Diagnoses 

    • Office/Progress Notes

  • Download Tremfya order form here. 

    Required clinicals: 

    • Negative TB test

    • Demographics

    • Labs & Tests Supporting Diagnoses 

    • Office/Progress Notes

  • Download Tysabri order form here.

    Required clinicals:

    • Demographics

    • Labs & Tests Supporting Diagnoses 

    • Office/Progress Notes

    • TOUCH portal enrollment

  • Download Uplizna order form here.

    Required clinicals: 

    • Negative Hep B

    • Negative TB

    • Demographics

    • Labs & Tests Supporting Diagnoses 

    • Office/Progress Notes

  • Download Ultomiris order form here.

    Required clinicals: 

    • Proof of meningococcal vaccination at least 2 weeks prior to start of treatment (If urgent Ultomiris therapy is indicated in an unvaccinated patient, administer meningococcal vaccine(s) as soon as possible and provide patients with two weeks of antibacterial drug prophylaxis

    • Demographics

    • Labs & Tests Supporting Diagnoses 

    • Office/Progress Notes

  • Download Vyepti order form here.

    Required clinicals:

    • Demographics

    • Labs & Tests Supporting Diagnoses 

    • Office/Progress Notes

  • Download Vyvgart order form here.

    Required clinicals:

    • Demographics

    • Labs & Tests Supporting Diagnoses 

    • Office/Progress Notes

  • Download Vyvgart Hytrulo form here.

    Required clinicals:

    • Demographics

    • Labs & Tests Supporting Diagnoses 

    • Office/Progress Notes

  • Download Xolair order form here.

    Required clinicals:

    • Demographics

    • Labs & Tests Supporting Diagnoses 

    • Office/Progress Notes