Patient Enrollment

Authorization for ScriptAssist
To enroll in the Asacol ScriptAssist program, please provide the following information:

Patient Information

Last Name

First Name

Date of Birth: Example: mm/dd/yy

Street

City

State

Zip

Home Phone

Work/Cell Phone

Special Instructions

Best Times to Call

Weekday Mornings (7 a.m. - 9 a.m.)

Weekdays (9 a.m. - 5 p.m.)

Weekday Evenings (5 p.m. - 8 p.m.)

Check if you do not want us to leave messages

Current Medication

The total number of tablet's I take per day is:

I take my medication:

Twice a day

Three times a day

Four times a day

Other

Physician Information

Physician's Name:

Address:

Ste:

City:

State:

Zip:

Phone:

Fax:

Physician Email:

Office Contact:

By submitting you agree to be contacted by
ScriptAssist regarding the patient support service.