Enroll Into Genentech Patient Support Services

Get started with the Patient Consent Form. This form gives us permission to discuss your health information with others, such as your doctor and your health insurance plan, so we can help you.

You can submit this form in 1 of 3 ways:

Submit it online

Fill out and submit the form online using eSubmit for faster and easier enrollment

Text a photo

Sign a printed form, take a photo and text it to (650) 877-1111

Send it via fax

Sign a printed form and fax or mail it to us (or give it to your doctor’s office to do so)

You must sign and date the form to enroll into Genentech patient support services. People prescribed Evrysdi® (risdiplam) must complete and sign the patient consent section (page 4) of the Evrysdi Start Form. This form is different from the Patient Consent Form.

Forms

Patient Consent Form

eSubmit View Download

Formulario de Consentimiento del Paciente

eSubmit View Download

Patient Consent Section of the Evrysdi Start Form

eSubmit View Download

Formulario de Inicio de Evrysdi

eSubmit View Download

please note

Your doctor also has to fill out a form called the Prescriber Service Form. Once we have both of 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.