Adempas Patient Enrollment and Consent Form 2026

1. Click ‘Get Form’ to open the Adempas Patient Enrollment and Consent Form in the editor.
2. Begin by filling out the 'Patient Information' section. Ensure all required fields marked with an asterisk (*) are completed, including first name, last name, birthdate, gender, and contact details.
3. For female patients, navigate to the 'Female Patient Agreement' section. Read through the statements carefully and provide your signature and date to confirm understanding of the risks associated with Adempas.
4. Proceed to 'Prescriber Information.' Fill in all necessary details about the prescriber, including their name, NPI number, and practice address.
5. In the 'Prescription' section, specify the initial dose of Adempas along with any special instructions for titration. Make sure to check the appropriate options regarding patient follow-up.
6. Complete the 'Prescriber Authorization' section by confirming reproductive status for female patients and providing your signature.
7. Finally, review all sections for accuracy before submitting. You can submit this form online or fax it as instructed at the end of the document.

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