® | As part of Diplomat Specialty Infusion Group®, InTouch Pharmacy is becoming Optum® Infusion Pharmacy.

Referral Forms

If you would like to refer a patient please print out the referral form and fill it out. If you don’t see the applicable specific form, just use your own General Prescription Form. Finally, please send the completed referral form to us via email or fax:

Email: info@intouchpharmacy.com

Fax: 404-973-2711

Dermatology- Orencia
Dermatology- Infliximab
Hemophilia and Bleeding Disorders
Rheumatology- Orencia
Rheumatology- Infliximab
IVIG Referral Form