Get started with enrollment by following the steps below.
If your practice has a registered account for My Patient Solutions, you can get started by logging into your account.
Don't have an account?
Your patient is required to complete the Patient Consent Form. You can either upload their Patient Consent Form as part of your application or have your patient submit the form via fax, text or e-submit.
An online tool to help you enroll patients in GAZYVA Access Solutions and manage your service requests at your convenience.
Step 1: Print one of the Patient Consent Forms below for your patient to complete.
Step 2: Print and complete the Prescriber Foundation Form below.
Step 3: Submit the completed forms via fax or text.
Both forms are required. We must have both the Patient Consent Form and the Prescriber Foundation Form before we can help you.
What to expect next:
We are open from 6AM-5PM PST, Mon. through Fri., except for the following holidays:
GAZYVA full Prescribing Information. South San Francisco, CA: Genentech, Inc.; 2022.
GAZYVA full Prescribing Information. South San Francisco, CA: Genentech, Inc.; 2022.
Mössner E, Brünker P, Moser S, et al. Increasing the efficacy of CD20 antibody therapy through the engineering of a new type II anti-CD20 antibody with enhanced direct and immune effector cell–mediated B-cell cytotoxicity. Blood. 2010;115(22):4393-4402.
Mössner E, Brünker P, Moser S, et al. Increasing the efficacy of CD20 antibody therapy through the engineering of a new type II anti-CD20 antibody with enhanced direct and immune effector cell–mediated B-cell cytotoxicity. Blood. 2010;115(22):4393-4402.
Herter S, Herting F, Mundigl O, et al. Preclinical activity of the type II CD20 antibody GA101 (obinutuzumab) compared with rituximab and ofatumumab in vitro and in xenograft models. Mol Cancer Ther. 2013;12(10):2031-2042.
Herter S, Herting F, Mundigl O, et al. Preclinical activity of the type II CD20 antibody GA101 (obinutuzumab) compared with rituximab and ofatumumab in vitro and in xenograft models. Mol Cancer Ther. 2013;12(10):2031-2042.
Klein C, Lammens A, Schäfer W, et al. Epitope interactions of monoclonal antibodies targeting CD20 and their relationship to functional properties. mAbs. 2013;5(1):22-33.
Klein C, Lammens A, Schäfer W, et al. Epitope interactions of monoclonal antibodies targeting CD20 and their relationship to functional properties. mAbs. 2013;5(1):22-33.
Honeychurch J, Alduaij W, Azizyan M, et al. Antibody-induced nonapoptotic cell death in human lymphoma and leukemia cells is mediated through a novel reactive oxygen species-dependent pathway. Blood. 2012;119(15):3523-3533.
Honeychurch J, Alduaij W, Azizyan M, et al. Antibody-induced nonapoptotic cell death in human lymphoma and leukemia cells is mediated through a novel reactive oxygen species-dependent pathway. Blood. 2012;119(15):3523-3533.
VENCLEXTA® (venetoclax tablets) Prescribing Information. North Chicago, IL: AbbVie Inc; 2022.
VENCLEXTA® (venetoclax tablets) Prescribing Information. North Chicago, IL: AbbVie Inc; 2022.
CALQUENCE® (acalabrutinib) Prescribing Information. Wilmington, DE: AstraZeneca Pharmaceuticals LP; 2019.
CALQUENCE® (acalabrutinib) Prescribing Information. Wilmington, DE: AstraZeneca Pharmaceuticals LP; 2019.
IMBRUVICA® (ibrutinib) Prescribing Information. Horsham, PA: Janssen Biotech, Inc.; 2022.
IMBRUVICA® (ibrutinib) Prescribing Information. Horsham, PA: Janssen Biotech, Inc.; 2022.
Data on file. Genentech, Inc.
Data on file. Genentech, Inc.
Seymour JF, Marcus R, Davies A, et al. Haematologica. 2019;104(6):1202-1208.
Seymour JF, Marcus R, Davies A, et al. Haematologica. 2019;104(6):1202-1208.
Casulo C, Byrtek M, Dawson KL, et al. J Clin Oncol. 2015;33(23):2516-2522.
Casulo C, Byrtek M, Dawson KL, et al. J Clin Oncol. 2015;33(23):2516-2522.
Canales M, Buchholz T, Izutsu K, et al. Obinutuzumab short duration infusion in previously untreated advanced follicular lymphoma: results from the end of induction analysis of the phase IV GAZELLE study. Presented at ASCO 2021.
Canales M, Buchholz T, Izutsu K, et al. Obinutuzumab short duration infusion in previously untreated advanced follicular lymphoma: results from the end of induction analysis of the phase IV GAZELLE study. Presented at ASCO 2021.
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