Enrollment and Consent Form

Fields marked with a * are required.

Pirfenidone, a generic alternative to ESBRIET®
I. PATIENT SECTION
II. ENROLLING HEALTHCARE PROFESSIONAL INFORMATION
III. NUTRITION
IV. PRESCRIPTION
V. PATIENT CONSENT

(NOTE: The verbal consent option only applies to provinces outside of Alberta. Under Alberta law, verbal consent is not permitted.)

VI. PHYSICIAN CONSENT

By signing below I confirm that: (i) I am the prescribing physician for this patient; (ii) this constitutes an original prescription for this patient [if applicable] and I authorize the JAMP Care Program to forward to the patient’s pharmacy of choice on my behalf; and (iii) subject to the patient’s consent, I agree to be contacted by the Program with regard to this patient to assist in administering the Program and providing patient care.

VII. CONSENT
If you have questions regarding the program, please contact the JAMP Care Patient Support Program: 1-888-202-8809

For more information about JAMP products, please call JAMP Pharma Medical Information Department at 1-866-399-9091 or by email at medinfo@jamppharma.com

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