Forms and Documents
Download the form you need to enroll in Genentech Access Solutions
and a helpful guide to use when talking to your doctor's office.
Start Enrollment With the Patient Consent Form
To get started, fill out the Patient Consent Form. This form replaces the Patient Authorization and Notice of Request for Transmission of Health Information to Genentech Access Solutions and Genentech® Access to Care Foundation (PAN).
You can complete this form in 1 of 3 ways:
- Fill out and submit the form online
- Sign a printed form, take a photo and text it to (650) 877-1111
- Sign a printed form and fax or mail it to us (or give it to your doctor's office to do so)
Your doctor also has to fill out a form called the Prescriber Service Form. Once we have both these forms, we can begin working with you and your doctor's office. You do not need to fill out anything on the Prescriber Service Form.
Treatment Cost Discussion Guide
This information packet includes:
- Questions to consider asking someone at your
doctor's office after you have been prescribed a Genentech
- Information on how to enroll in LUCENTIS
- A copy of the Patient Consent Form
Important Safety Information & Indication
What it Treats
Who is LUCENTIS for?
LUCENTIS® (ranibizumab injection) is a prescription medicine for the treatment of patients with:
- wet age-related macular degeneration (wAMD)
- macular edema following retinal vein occlusion (RVO)
- diabetic macular edema (DME)
- diabetic retinopathy (DR)
- myopic choroidal neovascularization (mCNV)
Important Safety Information
What important safety information should I know about LUCENTIS?
You should not use LUCENTIS if you have an infection in or around the eye or are allergic to LUCENTIS or any of its ingredients. LUCENTIS is a prescription medication given by injection into the eye, and it has side effects. Some LUCENTIS patients have had detached retinas and serious eye infections. If your eye becomes red, sensitive to light, or painful, or if you have a change in vision, call or visit your eye doctor immediately. Some LUCENTIS patients have had increased eye pressure before and within 1 hour of an injection. Uncommonly, LUCENTIS patients have had serious, sometimes fatal, problems related to blood clots, such as heart attacks or strokes. Fatal events were seen more often in patients with DME and DR with LUCENTIS compared with patients who did not receive Lucentis. Although there were only few fatal events which included causes of death typical of patients with advanced diabetic complications, these events may be caused by Lucentis.
Some LUCENTIS patients have serious side effects related to the injection. These include serious infections inside the eye, detached retinas, and cataracts. The most common eye-related side effects are increased redness in the white of the eye, eye pain, small specks in vision, and increased eye pressure. The most common non–eye-related side effects are nose and throat infections, anemia, nausea and cough. Ask your doctor if you have questions or want more information.
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.
For additional safety information, please talk to your doctor and see the LUCENTIS full prescribing information.