PRAXES Infusion Clinic Service Request Form

Thank you for your interest in our Infusion Clinic services!

The information collected in this form will allow us to assess your requirements, confirm our ability to meet them, and prepare a tailored quote with clear next steps.

If you have any questions, please contact sales@praxes.ca.

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Email: *

Infusion Clinic Services Required:

24/7/365 Telemedicine/Topside Assistance

Interested Service Plan? *

Core
Premium: includes PRAXES Connect
Elite: includes PRAXES Connect Elite Package
Unsure

Click Here to View our Service Plans

Planned Service Start Date? *

Please Note: Our minimum contract duration is one (1) year. Services can typically begin within 2 business days after client onboarding is complete, unless a later start date is requested.

Service Language Requirements? *

English
French & English

Will you be placing Telemedicine calls to PRAXES from Outside of Canada? *

Medical Role, Training, or Certification Level of On-Site Staff? Check all that apply. *

Nurse (e.g., RN, LPN)
Physician
PCP (Primary Care Paramedic)
ACP (Advanced Care Paramedic)
Other

If Other, please specify:

Number of Clinic Locations? *

Will you be Administering In-Home Infusions? *

Administered All Number

Generic Name of Each Infusion Medication Administered for All Clinic Locations. *

Drag & Drop Files, Choose Files to Upload You can upload up to 10 files.

Example: Infliximab

Will Antineoplastic Medications be Administered at Any Clinic Locations? *

Review of your Antineoplastic Medications Protocols will be required by our Medical Director and Operations Team prior to onboarding.

For the Infusion Medications listed above, does each Clinic have respective Medication Reaction Protocols? *

An infusion medication reaction protocol is a standardized set of clinical guidelines that healthcare providers follow to recognize, manage, and document adverse reactions that occur when a patient receives medication through an infusion.

Please upload copies of your Medication Reaction Protocols for our Medical Director’s review in the file area below. *

Drag & Drop Files, Choose Files to Upload You can upload up to 10 files.

Are you willing to collaborate with PRAXES’ Medical Directors to establish standardized Reaction Protocols for your Infusion Medications? *

Name of All Stock Medications Each Clinic Location Has On-Site. *

Drag & Drop Files, Choose Files to Upload You can upload up to 10 files.

Please upload a list of your stock medication in the file area above.

Do you require a PRAXES Certificate for Proof of Telemedicine coverage? *

Subscribe to Future PRAXES Communications? *

Yes, Please!
No, Thank You!