Formularios y Documentos

Descargue el formulario que necesita para inscribirse en Genentech Access Solutions y una guía útil para utilizarla en las consultas con su médico.

Iniciar la Inscripción con el Formulario de Consentimiento del Paciente

Para empezar, rellene el Formulario de Consentimiento del Paciente. Este formulario reemplaza la Autorización del Paciente y el Aviso de Solicitud Para Transmitir Información Médica a Genentech Access Solutions y a Genentech® Access to Care Foundation (PAN). 

Puede cumplimentar este formulario de 1 de estas 3 formas:

  • Rellene y envíe el formulario en línea
  • Firmando un formulario impreso, tomando una fotografía de este y enviándola por mensaje de texto al número  (650) 877-1111
  • Firmando un formulario impreso y enviarlo por fax o por correo postal (o bien llevándolo a la consulta de su médico para que lo envíen desde allí)

Su médico también tiene que rellenar un formulario llamado Formulario de Servicio del Prescriptor. Una vez que hayamos recibido estos dos formularios, podremos empezar a colaborar con usted y con la consulta de su médico. Usted no tiene que rellenar nada en el Formulario de Servicio del Prescriptor.

Guía de Discusión Sobre el Coste del Tratamiento

Este paquete de información incluye:

  • Cuestiones que debería plantearse preguntar al personal de su consultorio médico después de que se le haya recetado un medicamento de Genentech
  • Información para inscribirse en Genentech BioOncology Access Solutions
  • Una copia del Formulario de Consentimiento del Paciente

Important Safety Information & Indication

What it Treats

Important: If your healthcare provider prescribes ZELBORAF (vemurafenib), also read the Medication Guide that comes with ZELBORAF.

What is COTELLIC?

COTELLIC is a prescription medicine that is used with the medicine ZELBORAF, to treat a type of skin cancer called melanoma that has spread to other parts of the body or cannot be removed by surgery, and that has a certain type of abnormal “BRAF” gene.

Your healthcare provider will perform a test to make sure that COTELLIC is right for you.
It is not known if COTELLIC is safe and effective in children under 18 years of age.

Important Safety Information

  • Avoid sunlight during treatment with COTELLIC. COTELLIC can make your skin sensitive to sunlight. You may burn more easily and get severe sunburns. When you go outside, wear clothes that protect your skin, including your head, face, hands, arms, and legs. Use lip balm and a broad-spectrum sunscreen with SPF 30 or higher.
  • COTELLIC and ZELBORAF may cause serious side effects, including risk of new skin cancers, bleeding problems, heart problems, severe rash, eye problems, liver problems, muscle problems (rhabdomyolysis), and skin sensitivity to sunlight (photosensitivity).
  • Tell your doctor if you are pregnant or plan to become pregnant, as COTELLIC and ZELBORAF can harm your unborn baby. Females who are able to become pregnant should use effective birth control during treatment with COTELLIC and for 2 weeks after the final dose of COTELLIC.
  • Do not breastfeed during treatment and for 2 weeks after the final dose of COTELLIC. Talk to your heallthcare provider about the best way to feed your baby during this time.
  • Tell your healthcare provider about all the medicines you take. Some types of medicines will affect the blood levels of COTELLIC.
  • Common side effects of COTELLIC include diarrhea, sunburn or sun sensitivity, nausea, fever, and vomiting. COTELLIC can also cause changes in blood test results.

Tell your healthcare provider if you have any side effect that bothers you or that does not go away. These are not all the possible side effects of COTELLIC and ZELBORAF. 

Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088 or www.fda.gov/medwatch. You may also report side effects to Genentech at (888) 835-2555.

Please see Full COTELLIC Prescribing Information and Patient Information for additional Important Safety Information.