Resources

Prescribers/HCPs:

• Prescriber Enrollment Form
• Patient Enrollment Form
• Patient Baseline Form
• Medical and Reauthorization Form
• Discontinuation and Post-therapy Form
• Prescription and Reimbursement Services Form (optional)
• PROMACTA CARES Overview for Healthcare Professionals
• PROMACTA CARES Overview for Patients

Materials in Spanish:

• Patient Enrollment Form
• Prescription and Reimbursement Services Form (optional)
• Medication Guide for PROMACTA

Risk Monitoring:

When you report one of these events the appropriate form from the list below will be sent to you. You can also download the form here.

• Hepatobiliary Laboratory Abnormalities
• Worsening Thrombocytopenia and Bleeding
• Hematological Malignancy
• Bone Marrow Reticulin/Bone Marrow Fibrosis
• Thrombotic and Thromboembolic Events

Pharmacies:

• Hospital Pharmacy Authorization Form
• Dispensing Clinic Authorization Form
• VA Pharmacy Authorization Form
• Specialty Pharmacy Authorization Form
• Promacta Inventory Tracking Log
  • Adobe .pdf version
  • Excel spreadsheet version
• PROMACTA CARES Overview for Healthcare Professionals

Pregnancy Registry:

Pregnancy registry forms can be found on the Pregnancy Registry page.