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

Important Safety Information & Indication

What it Treats

What does PERJETA treat?

  • PERJETA® (pertuzumab) is approved for use in combination with Herceptin® (trastuzumab) and docetaxel in people who have HER2-positive breast cancer that has spread to different parts of the body (metastatic) and who have not received anti-HER2 therapy or chemotherapy for metastatic breast cancer.

PERJETA® (pertuzumab) is approved for use in combination with Herceptin® (trastuzumab) and chemotherapy for:

  • use prior to surgery (neoadjuvant treatment) in people with HER2-positive, locally advanced, inflammatory, or early stage breast cancer (tumor is greater than 2 cm in diameter or node-positive). PERJETA should be used as part of a complete treatment regimen for early breast cancer.
  • use after surgery (adjuvant treatment) in people with HER2-positive early breast cancer that has a high likelihood of coming back.

Important Safety Information

  • PERJETA may cause heart problems, including those without symptoms (such as reduced heart function) and those with symptoms (such as congestive heart failure)
  • Receiving PERJETA during pregnancy can result in the death of an unborn baby and birth defects
    • If you think you may be pregnant, you should contact your healthcare provider immediately
    • If you are exposed to PERJETA during pregnancy, or become pregnant while receiving PERJETA or within 7 months following the last dose of PERJETA in combination with Herceptin, you are encouraged to enroll in the MotHER Pregnancy Registry by contacting 1-800-690-6720 or visiting http://www.motherpregnancyregistry.com/ and report PERJETA exposure to Genentech at 1-888-835-2555
  • PERJETA should not be used in patients who are allergic to pertuzumab or to any of the ingredients in PERJETA
  • Other possible serious and sometimes fatal side effects of PERJETA therapy include:
    • Infusion-related reactions
    • Severe allergic reactions (hypersensitivity reactions/anaphylaxis)
  • The most common side effects of PERJETA when given with Herceptin and docetaxel for treatment of breast cancer that has spread to other parts of the body (metastatic) are:
    • Diarrhea
    • Hair loss
    • Low levels of white blood cells with or without fever
    • Nausea
    • Feeling tired
    • Rash
    • Damage to the nerves (numbness, tingling, pain in hands/feet)
  • The most common side effects of PERJETA when given with Herceptin and chemotherapy as part of an early breast cancer regimen before surgery are:
    • Constipation
    • Damage to the nerves (numbness, tingling, pain in hands/feet)
    • Diarrhea
    • Feeling tired
    • Hair loss
    • Headache
    • Low levels of red blood cells
    • Low levels of white blood cells with or without fever
    • Low platelet count
    • Mouth blisters or sores
    • Nausea
    • Pain in the muscles
    • Vomiting
    • Weakness

Side effects may vary based on chemotherapy regimen.

  • The most common side effects of PERJETA when given with Herceptin and chemotherapy as part of an early breast cancer regimen after surgery are:
    • Diarrhea
    • Nausea
    • Hair Loss
    • Feeling tired
    • Damage to the nerves (numbness, tingling, pain in hands/feet)
    • Vomiting

You are encouraged to report side effects to Genentech and the FDA. You may report side effects to the FDA at 1-800-FDA-1088 or http://www.fda.gov/medwatch. You may also report side effects to Genentech at 1-888-835-2555.

Please see full Prescribing Information for additional Important Safety Information, including most serious side effects.