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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 are dedicated to helping you understand your insurance coverage and assistance options. This can help you get the Genentech medicine your doctor prescribed.

Find Patient Assistance

Ready to Enroll?

Fill out the Patient Consent Form and send it to ALECENSA 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

Text a photo icon

Text a photo

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

Download and fax icon

Download and fax

Fax your completed and signed form to ALECENSA Access Solutions