Get Taiho Oncology Futibatinib (tas-120) Expanded Access Program (eap) Patient Access Form 2020-2025

This guide provides a comprehensive overview of how to complete the Taiho Oncology Futibatinib (TAS-120) Expanded Access Program (EAP) Patient Access Form online. Following these instructions will ensure that all necessary information is accurately gathered for submission.

Follow the steps to successfully complete the Patient Access Form.

1. Click the ‘Get Form’ button to access the Patient Access Form. This action will allow you to open the form for completion.
2. Begin by entering the physician's details. Fill out the sections for first name, last name, work email address, work telephone number, institution, street/address, city, state, zip code, and medical license number. Ensure all fields are completed using capital letters as specified.
3. Proceed to the delivery details section. Provide the pharmacist's details, including their first name, last name, work email address, work telephone number, pharmacist’s registration/license number, delivery address, and the name of the hospital or pharmacy.
4. In the patient information section, enter the patient’s initials, sex, year of birth, weight, and height. Specify the intended treatment and clearly state the main reason for applying for the Expanded Access Program.
5. Fill in the prior therapy section, detailing whether the patient has been intolerant or has clinically progressed on previous therapies. Provide a brief description as required.
6. Complete the physician declaration section by acknowledging the unlicensed nature of the request, collecting personal data, and consenting to the processing of that data as outlined. Sign and date the form as indicated.
7. Once all sections are completed and checked for accuracy, save changes to the form. You can then choose to download, print, or share the form for submission.

Take action now by completing the Taiho Oncology Futibatinib (TAS-120) Expanded Access Program Patient Access Form online.