AGRMT RE - OP SAMPLE PROGRAM FORM FOR INVEGA SUSTENNA WITH JANSSEN PHARMACEUTICAL.._.PDF

ONCE-MONMLY
INVEGA SUSTENNA"
paliporidone palmitate 2tIttr.
Outpatient Sample Prog
The Outpatient Sample Program is also available for inpatient facilities that are able to receive PDMA samples.
Return this completed form to request SAMPLES of INVEGA SUSTENNW (paliperidone palmitate) for new patient starts.
Fax to 1-844-727-4805 or mail to INVEGA SUSTENNA®, PO Box 6123, Lawrenceville, NJ 08648.
Asterisks (*) Indicate mandatory fields. For questions about this program or if you no longer wish to participate,
please call 1-855-463-1912, Monday through Friday, between 8 AM and 8 PM ET.
Please be advised that the personal information that you supply will be used to fulfill your request for samples and to send you Information regarding INVEGA SUSTENNir. This
Information will be shared with Janssen Pharmaceuticals, Inc., and the companies working for them to fulfill your request. Your name and the sample disbursement you received may
be reported as required by state or federal law. Once reported, this Information may be made available for public view. By submitting your Information, you agree to these terms and
that your information will be governed by our Privacy Policy, located at www. janssencns.com/prIvacy-policy.
Address* Suite/Floor/Building*
(Cannot ShIp10 PO Boxes)
State* ZIP*
State License #* Professional Designation* D MD CI DO Li NP Li PA
Phone* Fax*
Web Site
Please select the INVEGA SUSTENNA® product(s) that you would like to receive below.
Samples are limited to 6 units of each strength per request and are subject to
additional quantity limits. If no products are selected, no products will be sent.
CH 02 LI3 04 05 LI6
01 LI2 1:13 U4 LI 5 06
Paliperidone palmitate kit
Do NOT deliver on (check all that apply): LI Tuesday U Wednesday U Thursday U Friday
• 0
I treat patients with schizophrenia 18 years of age or older* CI Yes QNo
Licensed Practitioner's Signature* (no signature stamps, please) Date of Request* (void after 30 days)
MID-LEVELS ONLY: Supervising Physician's Specialty Jurisdictional Requirements
I certify that I am a licensed practitioner eligible to receive and prescribe these samples. If I am a Nurse Practitioner or Physician Assistant, I certify that I am authorized and eligible in the
state within which I am currently practicing, to request and receive these samples and that in states where required I have my supervising Physician's approval to do so. My signature on
this request certifies that I recognize that this Is a product sample for the needs of my patients and will not be sold, traded, bartered or returned for credit or submitted for third party
reimbursement. I understand that either my signature or the signature of a responsible person at ihe receiving facility Is required as a receipt of delivery. OHIO ONLY: By signing this
document, I attest that by requesting shipment of these drug samples, t am in compliance with the State of Ohio ORC 4729,51 (TODD license) or that the medical practice location meets
one of the licensing exemptions as outlined in the addendum provided at the lime of this request for samples,
FORM #* Representative Name* Representative Representative Representative
Signature* Territory* (7 digits) Phone*
1050041-SUS170114941
Before prescribing INVEGASUSTENNe, please see the full Prescribing Information, including Boxed WARNING.
INVEGASUSTENNg (paliperldone palmItate) Is manufactured by: Janssen Pharmaceutics NV, Beerse, Belgium. Distributed by: J. Knipper and Company, Inc.
Janssen Pharmaceuticals, Inc. 2017 Janssen
09/17 055004-170907 CR 11/17