Pulmozyme

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Patient Consent Form

Item # M-US-00002802(v1.0)

The Patient Consent Form replaces the PAN. This form is signed and dated by the patient, giving written permission for Genentech Access Solutions to discuss his or her health information with the practice and the patient's health insurance plan.

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Please complete the information below to place your order. If you would like to login, or create an account, you will not be required to fill in the information below. To login, or create an account, click here.
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By checking this box and submitting this form, you certify that you are a health care professional licensed in the United States or its territories and are indicating that you wish to receive communications about your order. Genentech's intent is to only provide information to health care professionals licensed in the United States or its territories who would likely be treating patients within the FDA-approved indications for these products.

 

I would like to register for Genentech updates and to be contacted by Genentech and its agents in the future regarding Genentech products and related disease education.

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