Please read the Prescribing Information for ONTRUZANT, including the
information about heart problems, infusion reactions (lung problems),
and harm to an unborn baby, and discuss it with your doctor.

ENROLL NOW

Please click on the links below to access The Organon Access Program forms that are applicable to you. If you are requesting a referral to the
Organon Patient Assistance Program, be sure to include all information, including a prescription from your health care provider for ONTRUZANT.
Please be sure all signatures are included prior to submitting forms to The Organon Access Program.

Option
1

SIGN AND SUBMIT
ELECTRONICALLY

Electronic Patient
Enrollment form

This patient form can be signed and submitted electronically. Please note that your health care provider must also submit the Health Care Provider Enrollment Form

Option
2

DOWNLOAD
& PRINT

ENROLLMENT FORM

This form can be downloaded and printed, and requires an original signature. Work with your health care provider to complete the enrollment form.

Sample
ENROLLMENT FORM

ENROLLMENT ASSISTANCE

Download and use this form as a guide
for completing the enrollment form.

Option 1

SIGN & SUBMIT
ELECTRONICALLY

Electronic Patient
Enrollment form

This patient form can be signed and submitted electronically. Please note that your health care provider must also submit the Health Care Provider Enrollment Form

Option 2

DOWNLOAD & PRINT

ENROLLMENT FORM

This form can be downloaded and printed, and requires an original signature. Work with your health care provider to complete the enrollment form.

ENROLLMENT ASSISTANCE

Sample
ENROLLMENT FORM

Download and use this form as a guide for completing the enrollment form.