Before you beginThis form is specific to your Vyepti® (eptinezumab) infusion at NerveSync Neurology. Please have your current medication list available. Questions? Call 08 6243 0334.
1
Patient Details
Personal and contact information
Required
Required
Required
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Valid email required
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2
Vyepti® Infusion Details
Dose, appointment, and transport
Prescribed Dose
✓
100 mg
Standard dose
IV infusion over 30 min
✓
300 mg
High dose
IV infusion over 30 min
100 mg dose: One 100 mg vial diluted in 100 mL 0.9% NaCl, infused over 30 minutes via a 0.2 micron in-line filter. Minimum 30-minute observation post-infusion.
300 mg dose: Three 100 mg vials combined, diluted in 100 mL 0.9% NaCl, infused over 30 minutes via a 0.2 micron in-line filter. Minimum 30-minute observation post-infusion.
Appointment
Required
Which cycle is this?
Transport
Required
You are advised not to drive for at least 30 minutes post-infusion. Discuss with your nurse if unsure.
3
Medical History
Allergies, medications, and health conditions
Allergies
Required (write "None" if none)
Previous Infusion Reactions
Current Medications
Required
General Health
Vyepti is not recommended during pregnancy. Discuss with your neurologist.
Vyepti-specific screeningThese questions help assess your suitability and ensure safe administration of eptinezumab. Please answer honestly — your clinical team will review this before your infusion.
4
Vyepti Pre-Infusion Screening
CGRP history, prior biologics, and safety checks
Migraine History
Previous CGRP Therapy
Prior Biologic / Immunotherapy
Infections & Vaccination
An active infection may require postponement. Please notify clinic staff.
Day of Infusion
Fasting is not required. Hydration is encouraged.
5
Risks & Informed Consent
Please read carefully and tick each item
About Vyepti® (Eptinezumab)
Vyepti (eptinezumab) is a humanised monoclonal antibody targeting calcitonin gene-related peptide (CGRP), a molecule involved in migraine. It is administered by IV infusion every 3 months to prevent migraine in adults with episodic or chronic migraine.
Known Risks & Side Effects
Nasopharyngitis (cold-like symptoms) — most common
Fatigue or drowsiness during / after infusion
Infusion site reactions (redness, swelling, pain)
Nausea or dizziness
Hypersensitivity reaction (rash, urticaria, flushing)
Anaphylaxis — rare (<1%), managed immediately on-site
Delayed infusion reaction (within 24 hrs post-infusion)
Urinary tract infection (reported in clinical trials)
All clinical staff are trained in anaphylaxis management. Emergency equipment including adrenaline, oxygen, and IV fluids is available at all times. You will be monitored for a minimum of 30 minutes after each infusion.
Informed Consent Declarations — Tick All Items
All 9 items must be ticked to proceed to the signature step.
6
Declaration & Signature
Sign to confirm your informed consent
By signing below, I confirm that all information I have provided is accurate and complete to the best of my knowledge, and that I have read and agreed to all consent declarations above.
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