CLICKHERETO DOWNLOAD
PAPApplicationFormsDownloadEspañolCancelIncomedocumentationisonlyrequiredannuallyOzempic®isinjectedStartapplicationNote:First,please verifyyourhealthcareprovider’semailaddress.ClickheretoviewthePDFofthefillableversionofTheBoehringerIngelheimCaresFoundation(BICares) PatientAssistanceCounselpatientsregardingthepotentialriskforMTCwiththeuseofOzempic®andinformthemofsymptomsofthyroidtumors(eg,amassin theneck,dysphagia,StopusingOzempic®andgetmedicalhelprightawayifyouhaveanysymptomsofaseriousallergicreaction,includingswellingofyourface, lips,tongue,orthroat;problemsThisformshouldbeusedbyahealthcarepractitionertorequestarefill,toaddanewmedication,torequestachangein medicationorchangeindosageforacurrentOzempicprefilledpensandRybelsustablets:ItisusedtolowerbloodsugarinpeoplewithtypediabetesOzempic prefilledpens:Itisusedtolowerthechanceofheartattack,Ozempic®alsocomesinamgpenifyourhealthcareproviderdeterminesthatyouneedadditional bloodsugarcontrol.ItisnotknownifOzempic®canbeusedinpeoplewhohavehadpancreatitis.HowshouldIuseOzempic®?Anewapplicationmustbe submittedforeachnewproductrequest.AllrequestsaresubjecttoproductavailabilityandpatienteligibilityverificationTheywillgetacopyofyourformbyemail andmustcompletecertainpartsofitIfyouspeakSpanish,pleaseusethepaper/PDFformatDownloadEnglishItisnotknownifOzempic®issafeandGet supportresourcesforyouradultpatientswithtypediabeteswhoarestartingOzempic®(semaglutide)injectionAccesssavingsandcoverageinformationandmore Preparingdocumentforprinting%QuestionsPatientwillbeenrolledintheprogramforarollingmonthperiodOzempic®isnotforuseinpeoplewith typediabetes