ONTRUZANT® (trastuzumab-dttb) Logo

Please read the Prescribing Information for ONTRUZANT, including the
information about heart problems, infusion reactions (lung problems),
and harm to an unborn baby, and discuss it with your doctor.


ENROLL NOW

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.

DOWNLOAD
& PRINT

These forms can be downloaded and
printed, and require an original signature.
Work with your health care provider to
complete the enrollment form.

Use this form to re-enroll in The Merck Access Program.

SIGN & SUBMIT
ELECTRONICALLY

This patient form can be signed and submitted
electronically. Please note that your health
care provider must also submit the
Health Care Provider Enrollment Form.

Use this form to re-enroll in The Merck Access Program.

ENROLLMENT ASSISTANCE

Download and use this form as a guide
for completing the enrollment form.

Contact The Merck Access Program Mon–Fri at 855-257-3932



 WELCOME TO

THE MERCK ACCESS PROGRAM

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