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 medicine
  • Information on how to enroll in PERJETA Access Solutions
  • A copy of the Patient Consent Form

Important Safety Information & Indication

What it Treats

What does PERJETA treat?

  • PERJETA® (pertuzumab) is approved for use in combination with Herceptin® (trastuzumab) and docetaxel in people who have HER2-positive breast cancer that has spread to different parts of the body (metastatic) and who have not received anti-HER2 therapy or chemotherapy for metastatic breast cancer.

PERJETA® (pertuzumab) is approved for use in combination with Herceptin® (trastuzumab) and chemotherapy for:

  • use prior to surgery (neoadjuvant treatment) in people with HER2-positive, locally advanced, inflammatory, or early stage breast cancer (tumor is greater than 2 cm in diameter or node-positive). PERJETA should be used as part of a complete treatment regimen for early breast cancer.
  • use after surgery (adjuvant treatment) in people with HER2-positive early breast cancer that has a high likelihood of coming back.

Important Safety Information

  • PERJETA may cause heart problems, including those without symptoms (such as reduced heart function) and those with symptoms (such as congestive heart failure)
  • Receiving PERJETA during pregnancy can result in the death of an unborn baby and birth defects
    • If you think you may be pregnant, you should contact your healthcare provider immediately
    • If you are exposed to PERJETA during pregnancy, or become pregnant while receiving PERJETA or within 7 months following the last dose of PERJETA in combination with Herceptin, you are encouraged to enroll in the MotHER Pregnancy Registry by contacting 1-800-690-6720 or visiting http://www.motherpregnancyregistry.com/ and report PERJETA exposure to Genentech at 1-888-835-2555
  • PERJETA should not be used in patients who are allergic to pertuzumab or to any of the ingredients in PERJETA
  • Other possible serious and sometimes fatal side effects of PERJETA therapy include:
    • Infusion-related reactions
    • Severe allergic reactions (hypersensitivity reactions/anaphylaxis)
  • The most common side effects of PERJETA when given with Herceptin and docetaxel for treatment of breast cancer that has spread to other parts of the body (metastatic) are:
    • Diarrhea
    • Hair loss
    • Low levels of white blood cells with or without fever
    • Nausea
    • Feeling tired
    • Rash
    • Damage to the nerves (numbness, tingling, pain in hands/feet)
  • The most common side effects of PERJETA when given with Herceptin and chemotherapy as part of an early breast cancer regimen before surgery are:
    • Constipation
    • Damage to the nerves (numbness, tingling, pain in hands/feet)
    • Diarrhea
    • Feeling tired
    • Hair loss
    • Headache
    • Low levels of red blood cells
    • Low levels of white blood cells with or without fever
    • Low platelet count
    • Mouth blisters or sores
    • Nausea
    • Pain in the muscles
    • Vomiting
    • Weakness

Side effects may vary based on chemotherapy regimen.

  • The most common side effects of PERJETA when given with Herceptin and chemotherapy as part of an early breast cancer regimen after surgery are:
    • Diarrhea
    • Nausea
    • Hair Loss
    • Feeling tired
    • Damage to the nerves (numbness, tingling, pain in hands/feet)
    • Vomiting

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

Please see full Prescribing Information for additional Important Safety Information, including most serious side effects.