DALVANCE® (Dalbavancin)
Order Form

DALVANCE®

DALVANCE® (dalbavancin) for injection is indicated for the treatment of adult and pediatric patients with acute bacterial skin and skin structure infections (ABSSSI) caused by designated susceptible strains of Gram-positive microorganisms. To reduce the development of drug-resistant bacteria and maintain the effectiveness of DALVANCE and other antibacterial agents, DALVANCE should be used only to treat or prevent infections that are proven or strongly suspected to be caused by susceptible bacteria.

For more information, please refer to the Dalvance website, full prescribing information and important safety information.

Note: Please speak with your healthcare provider for more information if you think this therapy might be right for you.

How do I make a referral or transition my treatment to Infusion Associates?

1. Ask your healthcare provider to fax us a completed order form for your medication, clinical notes, demographics and your insurance card to (616) 954-1675.

2. Providers can find order forms on our medications page.

3. One of our intake specialists will contact you to confirm receipt of your referral.

4. We will then verify benefits, obtain any required prior authorizations, and contact you to schedule an appointment.