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Submit the Patient Consent Form online using eSubmit. You do not have to create a signature with your finger or the mouse to sign the form.

We understand the many challenges you may be facing during these difficult times. Getting your prescribed medicines should not be one of them. If you are concerned about paying for your Genentech medicine, please call our Patient Resource Center at (877) 436-3683.

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Ready to Enroll?

Fill out the Patient Consent Form and send it to Genentech Access Solutions to get started. The form can be submitted in any of these 3 ways:

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Submit online

Fill out and submit the form online

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Text a photo

Take a photo of your signed form and text it to Genentech Access Solutions

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Download and fax

Fax your completed and signed form to Genentech Access Solutions