Formularios y Documentos

Aquí puede descargar el formulario que necesita para inscribirse en LUCENTIS Access Solutions y otra información importante. Recuerde que su médico también debe rellenar un formulario para inscribirle.

Iniciar la Inscripción con el Formulario PAN

Para empezar, rellene el formulario llamado PAN. Puede encontrar el formulario a continuación.

SMN

Su médico también tiene que rellenar un formulario llamado SMN. Cuando tengamos estos dos formularios, podremos empezar a trabajar con usted y la consulta de su médico. Usted no tiene que rellenar ningún dato en este formulario.

Preguntas y Consideraciones Que Hacer en la Consulta de Su Médico

Este paquete de información incluye:

  • Una copia del formulario PAN
  • Una lista de preguntas que podrían surgirle

Alguien de la consulta de su médico debería poder responder a estas preguntas cuando le hayan prescrito un medicamento de Genentech.

PAN=siglas en inglés de Autorización del Paciente y Aviso de Solicitud Para Transmitir Información Médica a Genentech Access Solutions y a Genentech® Access to Care Foundation.

SMN=siglas en inglés de Declaración de Necesidad Médica.

Important Safety Information & Indication

What it Treats

LUCENTIS® (ranibizumab injection) is a prescription medicine for the treatment of patients with:

  • wet age-related macular degeneration (wAMD),
  • macular edema following retinal vein occlusion (RVO)
  • diabetic macular edema (DME)
  • diabetic retinopathy (DR) with DME
  • myopic choroidal neovascularization (mCNV)

Important Safety Information

You should not use LUCENTIS if you have an infection in or around the eye or are allergic to LUCENTIS or any of its ingredients. LUCENTIS is a prescription medication given by injection into the eye, and it has side effects. Some LUCENTIS patients have had detached retinas and serious eye infections. If your eye becomes red, sensitive to light, or painful, or if you have a change in vision, call or visit your eye doctor immediately. Some LUCENTIS patients have had increased eye pressure before and within 1 hour of an injection. Uncommonly, LUCENTIS patients have had serious, sometimes fatal, problems related to blood clots, such as heart attacks or strokes. Fatal events were seen more often in patients with DME and DR with LUCENTIS compared with patients who did not receive Lucentis. Although there were only few fatal events, which included causes of death typical of patients with advanced diabetic complications, these events may be caused by Lucentis.

Some LUCENTIS patients have serious side effects related to the injection. These include serious infections inside the eye, detached retinas, and cataracts. The most common eye-related side effects are increased redness in the white of the eye, eye pain, small specks in vision, and increased eye pressure. The most common non–eye-related side effects are nose and throat infections, anemia, nausea and cough. Ask your doctor if you have questions or want more information.

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.

For additional safety information, please see LUCENTIS full prescribing information.