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

Important Safety Information & Indication

What it Treats

What is ZELBORAF? 

ZELBORAF is a prescription medicine used 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 has a certain type of abnormal BRAF gene.

Your healthcare provider will perform a test to make sure that ZELBORAF is right for you. ZELBORAF is not used to treat melanoma with a normal BRAF gene.

ZELBORAF is a prescription medicine used to treat a type of blood cell cancer called Erdheim–Chester disease (ECD), that can affect body tissues and organs, and that has a certain type of abnormal “BRAF” gene.

Important Safety Information

ZELBORAF can cause serious side effects, including risk of new cancers. ZELBORAF may cause certain types of skin cancer called cutaneous squamous cell carcinoma (cuSCC) and keratoacanathoma. New melanoma lesions have occurred in people who take ZELBORAF. ZELBORAF may also cause another type of cancer called non-cutaneous squamous cell carcinoma (non-cuSCC). Talk with your healthcare provider about your risk for these cancers. Check your skin and tell your healthcare provider about skin changes, including a new wart, a sore or bump that bleeds or does not heal, or a mole that changes size or color.

Your healthcare provider should also check for cancers that may not occur on the skin. Tell your healthcare provider about any new symptoms that you get while taking ZELBORAF.

Other blood cancers have happened in some people with Erdheim-Chester Disease (ECD) including those who take ZELBORAF. If you have other blood cancers and take ZELBORAF for ECD, your healthcare provider will monitor your blood cancer through routine blood tests.

While taking ZELBORAF, you should avoid sunlight. 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.

Possible serious side effects of ZELBORAF include severe allergic reactions, severe skin reactions, potentially life-threatening changes in the electrical activity of your heart called QT prolongation, liver injury, eye problems, worsening side effects from radiation treatment, kidney injury, and connective tissue disorders.

Tell your healthcare provider if you are pregnant, or plan to become pregnant, as ZELBORAF can harm your unborn baby. Females who are able to become pregnant should use effective birth control during ZELBORAF treatment and for 2 weeks after the final dose.

Tell your healthcare provider if you are breastfeeding or plan to breastfeed. Do not breastfeed during treatment with ZELBORAF and for 2 weeks after the final dose. Talk to your healthcare provider about the best way to feed your baby during this time.

Tell your healthcare provider about all the medicines you take.

Common side effects of ZELBORAF include joint pain, rash, hair loss, tiredness, sunburn or sun sensitivity, nausea, itching, warts, or QT prolongation.

These are not all of the possible side effects of ZELBORAF. 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 accompanying Full Prescribing Information and Medication Guide for additional Important Safety Information.