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 Erivedge Access Solutions
  • Una copia del Formulario de Consentimiento del Paciente

Important Safety Information & Indication

INDICATION

Erivedge® (vismodegib) capsule is a prescription medicine used to treat adults with a type of skin cancer, called basal cell carcinoma, that has spread to other parts of the body or that has come back after surgery or that your healthcare provider decides cannot be treated with surgery or radiation.

It is not known if Erivedge is safe and effective in children.

Serious Side Effects

Erivedge can cause your baby to die before it is born (be stillborn) or cause your baby to have severe birth defects.

Important Safety Information

What is the most important information I should know about Erivedge?

  • Erivedge can cause your baby to die before it is born (be stillborn) or cause your baby to have severe birth defects
  • For females who can become pregnant, talk with your healthcare provider about the risks of Erivedge to your unborn child. Your healthcare provider will do a pregnancy test within 7 days before you start taking Erivedge. Avoid pregnancy by using birth control during treatment and for 24 months after your final dose. Tell your healthcare provider right away if you have unprotected sex or think that your birth control has failed
  • For males, Erivedge is present in semen. Do not donate semen while you are taking Erivedge and for 3 months after your final dose. You should always use a condom, even if you have had a vasectomy, during sex with female partners who are pregnant or who are able to become pregnant, during treatment with Erivedge, and for 3 months after your final dose to protect your female partner from being exposed to Erivedge
  • Tell your healthcare provider right away if you or your female partner could be pregnant or thinks she is pregnant while you are taking Erivedge

Exposure to Erivedge during pregnancy:

If you become pregnant during treatment with Erivedge, you or your healthcare provider should report your pregnancy to Genentech at (888) 835-2555.

What should I tell my healthcare provider before taking Erivedge?

  • If you are pregnant or plan to become pregnant
  • If you are breastfeeding or plan to breastfeed. You should not breastfeed during treatment and for 24 months after your final dose of Erivedge.
  • About all the medicines you take

What should I avoid while taking Erivedge?

  • Do not donate blood or blood products while you are taking Erivedge and for 24 months after your final dose
  • Do not donate semen while you are taking Erivedge and for 3 months after your final dose

What are the possible side effects of Erivedge?

  • Bone growth problems. Bone growth problems have happened in children who have been exposed to Erivedge. These problems may continue even after stopping treatment with Erivedge
  • The most common side effects of Erivedge are:
    • Muscle spasms
    • Hair loss
    • Change in how things taste or loss of taste
    • Weight loss
    • Tiredness
    • Nausea
    • Diarrhea
    • Decreased appetite
    • Constipation
    • Joint pain 
    • Vomiting

Erivedge can cause absence of menstrual periods (amenorrhea) in females who are able to become pregnant. It is not known if amenorrhea is permanent. Talk to your healthcare provider if you have concerns about fertility.

These are not all of the possible side effects of Erivedge. Because everyone is different, it is not possible to predict what side effects any one person will have or how severe they may be. Call your doctor for medical advice about side effects.

You may report side effects to the FDA at (800) FDA-1088 or www.fda.gov/medwatch. You may also report side effects to Genentech at (888) 835-2555.

Please see full Prescribing Information for additional Important Safety Information, including serious side effects, and the Medication Guide.