Please click on the links below to access The Merck Access Program forms that are applicable to you. If you are requesting a referral to the
Merck Patient Assistance Program, be sure to include all information, including a prescription from your health care provider for ONTRUZANT.
Please be sure all signatures are included prior to submitting forms to The Merck Access Program.
These forms can be downloaded and
printed, and require an original signature.
Work with your health care provider to
complete the enrollment form.