Please click on the links below to access The Merck Access Program forms that are applicable to you. If your patient is requesting a referral to the Merck Patient Assistance Program, be sure to include all information, including a prescription 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.
These forms can be signed and
Use this form if the patient is in the office and
you are able to complete the form together.