IRESSA Access Program Forms
The forms below need to be filled out and submitted to the IRESSA ACCESS PROGRAM to enable renewal prescriptions to be filled for existing IRESSA patients after September 15, 2005. There are two forms, one for patients and one for physicians. If you are a patient, please read through the patient form and discuss it with your doctor. Your physician will need to send in your signed form along with the signed physician form and a renewal prescription for IRESSA in order for you to fill a prescription after September 15, 2005 for existing patients or for patients.
Click here for the IRESSA Access Program Patient Consent Form
Click here for IRESSA Access Program Physician Certification Form
Please click here for Full Prescribing Information
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