The pharmacy chosen: Fill out & sign online

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01. Edit your form online

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02. Sign it in a few clicks

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03. Share your form with others

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How to use or fill out the ZUBSOLV Patient Assistance Program with our platform

Ease of Setup

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Ease of Use

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Click ‘Get Form’ to open it in the editor.
Begin by filling out your personal information in the 'YOUR INFORMATION' section. Include your name, address, phone number, and email. Ensure all fields are completed accurately.
In the 'ELIGIBILITY INFORMATION' section, indicate your residency status and annual household income. Attach the required supporting documentation as specified.
Proceed to the 'MEDICAL QUESTIONS' section. List all medications you are currently taking and any allergies you may have. If applicable, check the box for 'NONE'.
Sign and date the application in 'THE AGREEMENT' section to confirm that all information is true and complete.
Ensure that your prescriber completes page 3 of the application, including their signature and prescription details for ZUBSOLV.
Finally, submit your completed application by mailing it to the address provided or have your prescriber fax it directly.

Start using our platform today to simplify your application process for ZUBSOLV!

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