Patient Support Program Enrolment Forms

This page features links to download the enrolment forms of a number of Patient Support Programs. These programs are organized by pharmaceutical companies and are intended for patients that have been prescribed their medications.

Actemra Joint Effort – RA, JIA

Actemra (tocilizumab) Joint Effort support program for Rheumatoid Arthritis and Systemic Juvenile Idiopathic Arthritis. The form includes sections for both IV and SC Actemra.

• Actemra Joint Effort for Rheumatoid Arthritis (PDF)
• Actemra Joint Effort for Systemic Juvenile Idiopathic Arthritis (PDF)

Contact the Joint Effort patient support program at 1-888-748-8926.

Benlysta Monarch

Benlysta (belimumab) Monarch Program for patients:

• Benlysta Monarch Program Enrolment Form (PDF)
• Benlysta Medical Order Form (PDF)

Contact the Benlysta Monarch support program at 1-855-788-3135.

Brenzys Harmony

Brenzys (etanercept) support program form:

• Brenzys Harmony Enrolment Form (PDF)

Contact the Harmony patient support program at 1-866-556-5663.

Cimzia Solutions

Cimzia (certolizumab) Solutions support program:

• Cimzia Solutions Patient Support Program Enrolment Form (PDF)

Contact the Cimzia Solutions patient support program at 1-800-908-5555.

Cosentyx XPOSE

Cosentyx (secukinumab) XPOSE patient support program:

• Cosentyx XPOSE Support Program Enrolment Form (PDF)

Contact the Xpose patient support program at 1-844-27XPOSE (1-844-279-7673).

Enbrel Enliven

Enbrel (etanercept) Enliven enrolment form:

• Enliven Enrolment Form (PDF)

Contact the Enliven patient support program at 1-877-936-2735.

Humira Progress

Humira (adalimumab) Progress patient program enrolment form:

• Humira Progress Form (PDF)

Contact the Progress patient support program at 1-866-848-6472.

Inflectra Program – RA

Inflectra (infliximab) for Rheumatoid Arthritis patient support program.

• Inflectra Enrolment Form (PDF)

Contact the Inflectra patient support program at 1-844-466-6627.

Kevzara Mobilize Program

Kevzara (sarilumab) support program form:

• Kevzara Mobilize Enrolment Form (PDF)

Contact the Mobilize patient support program at 1-888-972-6634.

Orencia Response Program

Orencia (abatacept) Response Program consent and enrolment form:

• Orencia Response Program Enrolment Form (PDF)

Contact the Orencia Response patient support program at 1-877-979-3200.

Remicade Bioadvance

Remicade (infliximab) Bioadvance enrolment form:

• Remicade Bioadvance Enrolment Form (PDF)

Rituxan Joint Effort – RA, GPA, MPA

Rituxan (rituximab) Joint Effort enrolment forms for Rheumatoid Arthritis, and for Granulomatosis with Polyangiitis (GPA) and Microscopic Polyangiitis (MPA):

• Rituxan Joint Effort Enrolment Form (RA) (PDF)
• Rituxan Joint Effort Enrolment Form (GPA, MPA) (PDF)

Contact the Joint Effort patient support program at 1-888-532-1198.

Simponi Bioadvance

Simponi (golimumab) Bioadvance enrolment, Rx, and consent forms:

• Simponi Bioadvance Forms – Injectable (SC) (PDF)
• Simponi Bioadvance Forms – Intravenous (IV) (PDF)

Xeljanz eXel – RA

Xeljanz (tofacitinib) for Rheumatoid Arthritis Enrolment Form:

• Xeljanz eXel Form (PDF)

Contact the eXel patient support program at 1-855-XEL-EXEL (1-855-935-3935).