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

Important Safety Information & Indication

What it Treats

Indication and Usage

Pulmozyme (dornase alfa) is indicated for daily administration along with standard therapies for the management of cystic fibrosis (CF) patients to improve pulmonary function.

In CF patients with an FVC
≥ 40% of predicted, daily administration of Pulmozyme has also been shown to reduce the risk of respiratory tract infections requiring injectable antibiotics.

Important Safety Information

Pulmozyme should not be used in patients who are allergic to any of its ingredients.

Patients may experience the following when using Pulmozyme: change in or loss of their voice, discomfort in the throat, rash, chest pain, red watery eyes, runny nose, lowering of lung function, fever, indigestion, and shortness of breath. There have been no reports of severe allergic reactions caused by the administration of Pulmozyme. Mild to moderate hives and mild skin rash have been observed and have been short-lived.

Pediatric Use

The safety and effectiveness of Pulmozyme have been established in patients 5 years of age and older. While clinical trial data are limited in patients younger than 5 years of age, the use of Pulmozyme should be considered for pediatric CF patients who may experience potential benefit in lung function or who may be at risk of respiratory tract infection.

The safety of Pulmozyme given by daily inhalation for 2 weeks has been studied using 98 CF patients with 65 of them aged 3 months to <5 years (younger group) and 33 aged 5 years to <10 years (older group). The PARI BABY™ reusable nebulizer (which uses a face mask instead of a mouthpiece) was used in patients who were unable to show that they could breathe in or out using their mouth throughout the entire treatment period. Overall, the kind of side effects observed in children was similar to those seen in larger trials in older patients.

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 www.fda.gov/medwatch. You may also report side effects to Genentech at 1-888-835-2555.

Please see full Pulmozyme Prescribing Information for additional Important Safety Information. If you have questions, please discuss them with your CF Care Team.