Plan request

Zoledronic Acid Infusion

Patients who have received a Zoledronic Acid infusion within the past year are not eligible.

Complete this form as comprehensively as possible, then select Save as PDF and send it to us. If you'd rather fill it out by hand, instead.

Unfortunately, we cannot enter therapy plans for those under the age of 18.

Requesting Prescriber Details

Full Name Required

PracID Required

Clinic Name Required

Fax Number Required

Patient Demographics

(You may attach a patient label if completing the form manually)

Last Name

First Name

Healthcare Number Required

Date of Birth

Telephone Number Required

Preferred Day Medicine site Required

Foothills Medical Centre Peter Lougheed Centre Rockyview General Hospital South Health Campus UrgentAll urgent requests are usually booked at South Health Campus. Your patient must be willing to travel there on short notice.

Pertinent Medical History

(You may enter information here, OR attach details to this form when submitting)

Medical and Surgical History Required

Current Medications Required

Allergies Required

No known allergies Other

Indications for Bisphosphonate

We follow Calgary Day Medicine Guidelines for Bisphosphonate Infusion. To qualify, the patient must not have had Denosumab in the past 6 months or Zoledronic Acid in the past 12 months, and must not be pregnant or breastfeeding.

Reason for IV Zoledronic Acid Required

Osteoporosis with contraindication to Oral Bisphosphonate Osteoporosis with gastrointestinal intolerance to Alendronate / Risedronate Osteoporosis with unsatisfactory response to oral treatment (bone mineral density lower than pre-treatment with oral medication, or fragility fracture despite 1 year of Alendronate / Risedronate) Other

Zoledronic Acid Product

Select all that apply.

Infusion Product Required

Zoledronic Acid 0.05 mg/ml Patient has had IV Bisphosphonate before Requesting provider has reviewed risks and benefits of IV Bisphosphonate

Zoledronic Acid Infusion Requested and Special Authorization

If these fields are not completed, we may not be able to enter your Therapy Plan Request in a timely manner.

Please provide your patient with a prescription and a Blue Cross Special Authorization form (if applicable) for Zoledronic Acid 0.05 mg/ml. They must collect the prescribed medication at the pharmacy and bring it to the infusion appointment at Day Medicine.

There is no charge for adult Day Medicine Infusion appointments, but failure to show may result in cancellation of the therapy plan.

Confirmations Required

Requesting Practitioner has confirmed Alberta Blue Cross coverage and provided a prescription The patient has been informed that they must collect the medication at a community pharmacy and bring the product with them to the infusion appointment

Save this form as a PDF, so you can print it and fax it to us at (403) 879-5049.