Date of referral

Robina Private Hospital Anti-Amyloid Therapy Referral

A referral for patients that have a formal diagnosis of Alzheimer’s disease and are seeking Lecanemab (Leqembi®) or Donanemab (Kisunla®) therapy.

Referrer Details

Given name *

Family name *

Specialty

Provider number

If other qualification, please enter here

Hospital/Practice name *

Hospital/Practice phone number *

Hospital/Practice fax number

Please provide your email to receive a copy of this referral submission *

Practice Address *

Street address *

City *

State *

Postcode *

Would you like to be contacted about CPD education events and the hospital’s services?

Patient Information

Given name *

Family name *

Date of Birth *

Patient phone number *

Patient email

Patient address *

City *

State *

Postcode *

Does the patient have an Enduring Power of Attorney *

YesNo

If yes, please provide name / relationship and phone number:

Name

EPOA Contact Number

Relationship

The patient is aware of the referral and agrees to be contacted by Robina Private Hospital *

Patient Next of Kin

Name *

Relationship *

Contact number *

Patient GP Details

Name *

Practice Phone Number *

GP Practice *

SECTION 1 — TRIAGE SUMMARY

Please consider the following before referral.

Requirement

Confirmed Alzheimer's diagnosis
Amyloid confirmation (PET or CSF)
Brain MRI using GRE and SWI with ARIA, amyloid imaging abnormality assessment preferable and local access to MRI available such as patient can access the same machine for comparison.
APOE ε4 genotyping status
Baseline bloods, coagulation and renal function to consider.
Any Cardiac issues such as Atrial Fibrillation
MMSE
Care partner identified and engaged

SECTION 2 — AMYLOID STATUS (Confirmed positive)

Confirmation Method

Amyloid PET

Report attached

YesNo

Result Positive Date:

CSF Aβ42/40 ratio

p-tau/Aβ42

Date

TAU / SUPPLEMENTARY BIOMARKERS (If available)

CSF tau / p-tau

Plasma p-tau217

p -tau 181 blood test

SECTION 3 — NEUROIMAGING SUMMARY (MRI required within 6 months prior to initiation)

Date of Brain MRI

Report attached

YesNo

MRI Baseline ARIA eligibility checklist — all preferable to be absent or within acceptable limits:

MRI FindingMacrohemorrhage >1 cm
Microhemorrhages (number: ___)
Superficial siderosis
Cortical infarcts
Lacunar infarcts (number: ___)
Fazekas grade 3 White Matter Disease
Cerebral Amyloid Angiopathy
CAA features
Other major intracranial pathology

If any item is marked present, provide details, numbers and clinical rationale for proceeding:

SECTION 4 — THERAPY REQUEST

Requested agent

Lecanemab (age 50–90; MMSE ≥22) Donanemab (age 60–85; MMSE greater than or equal to 20/30)Either agent — defer to prescribing clinician's judgment

SECTION 5 — SAFETY COSNIDERATIONS

No anticoagulant use (or risk formally assessed)
Blood pressure adequately controlled
No recent stroke / TIA (12 months)
No active malignancy
No active or unstable psychiatric disorder
No known serious hypersensitivity to monoclonal antibodies
Non-AD diagnoses excluded (FTD, LBD, vascular dementia)
Renal function acceptable (eGFR: ___)
Unstable arrythmia eg. AF, SVT
APOE STATUS 4/4

If any item is marked present, provide details, numbers and clinical rationale for proceeding:

SECTION 6 — ADDITIONAL CLINICAL NOTES

(Include neuropsychological testing, comorbidity detail, psychiatric history, advance care planning documents, or other pertinent clinical context) *

If other support required, please specify

Upload PET and MRI scans, if available

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Submission of an online referral does not does not automatically constitute acceptance of the referral. We will contact your patient, and you will be advised of the outcome.

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