LEMTRADA REMS PATIENT ENROLLMENT FORM

For Patients to Complete
LEMTRADA REMS PATIENT ENROLLMENT FORM
Please fax this completed form to the LEMTRADA REMS Program at 1-855-557-2478
This form must be completed before you can receive LEMTRADA® (alemtuzumab).
LEMTRADA is available only through a restricted distribution program called the LEMTRADA
REMS Program. Your prescriber will help you complete this form and will give you a copy.
*Indicates a mandatory field.
PATIENT INFORMATION (PLEASE PRINT)
Name (Last, First)*
Date of Birth (MM/DD/YYYY)*
Street Address*
City*
Phone Number*
Gender*
Secondary Contact (Last, First)
Phone Number
State*
Male
ZIP Code*
Female
PRESCRIBER INFORMATION (PLEASE PRINT)
Prescriber Name (Last, First)*
NPI Number*
Phone Number*
PATIENT AGREEMENT
By signing this form, I acknowledge that:
I have received, read, and understand What You Need to
Know About LEMTRADA Treatment: A Patient Guide that my
doctor has given to me.
My doctor has reviewed with me the benefits and risks of
treatment with LEMTRADA.
I am aware that LEMTRADA is associated with serious risks,
including autoimmune conditions, infusion reactions, and
malignancies, and that these complications can be identified
through periodic monitoring and awareness of the initial signs
and symptoms.
I understand the need to have blood and urine tests
within 30 days prior to my first LEMTRADA treatment,
then each month for 4 years following my last treatment
with LEMTRADA.
I understand the need to have thyroid testing within 30 days
prior to my first LEMTRADA treatment, then every 3 months
for 4 years following my last treatment with LEMTRADA.
I understand the need to have yearly skin exams prior to
my first LEMTRADA treatment, and continuing for 4 years
following my last treatment with LEMTRADA.
I will tell my doctor if I have any reactions or symptoms
after receiving LEMTRADA.
I understand that I must tell all of my doctors that I have
received LEMTRADA.
I understand that in order to receive LEMTRADA, I am required
to enroll in the LEMTRADA REMS Program and my information
will be stored in a secure and confidential database of all patients
who receive LEMTRADA in the United States. After enrolling, my
doctor will provide me with a signed copy of the enrollment form.
My doctor has counseled and provided me with a LEMTRADA Patient
Safety Information Card, which I should carry with me at all times
in case of an emergency.
I understand that I must tell Genzyme if I change my doctor.
I understand that I must tell Genzyme if my contact information
changes.
I give permission to Genzyme and its agents to use and share my
personal health information for the purposes of enrolling me
into the LEMTRADA REMS Program, coordinating the dispensing of
receiving LEMTRADA, administering the LEMTRADA REMS Program,
and releasing my personal health information to the Food and Drug
Administration (FDA) as necessary.
By completing the information below, I understand Genzyme and
its agents will contact me via phone, mail, or email to support
administration of the LEMTRADA REMS Program.
I prefer to be contacted:
By mail
By phone
By email (please provide email address)
PATIENT SIGNATURE
Patient/Legal Representative Signature*
Relationship to Patient*
Print Name*
Date*
PRESCRIBER SIGNATURE
I acknowledge that I have explained the LEMTRADA REMS Program to this patient.
Prescriber Signature*
Date*
Please fax this completed form to the LEMTRADA REMS Program at 1-855-557-2478
If you have any questions regarding the LEMTRADA REMS Program, call 1-855-676-6326
LEMTRADA and Genzyme are registered trademarks of Genzyme Corporation.
©2015 Genzyme Corporation, a Sanofi company. All rights reserved. US.MS.LEM.14.10.007-v2