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Dermatology Enrollment Form

$399.95 $27.95

Dermatology Enrollment Form

The Dermatology Enrollment Form is for pharmacies to offer prescribers who diagnose patients with psoriasis or eczema.

The form is easy to fill out online or in print format.

The following drugs are available to quickly prescribe on the form:

  • Cosentix 150mg, 300mg Pen & PFS, and
  • Dupixent 300mg/2mL, and
  • Enbrel 25mg/50mg Sureclick, Prefilled, Mini Cartridge, and Vials, and
  • Erivedge 150mg, and
  • Humira starter & 40mg pen and prefilled, and
  • Odomzo 200mg caps, and
  • Otezla starter, 30mg tabs, and
  • Siliq 210mg prefilled, and
  • Simponi 50mg, Smartject, PFS, and
  • Stelara 45mg, 90mg, and
  • Tremfya TM 100mg prefilled, and

The form is available for download after purchase as an Adobe PDF document, and it is interactive.

SKU: PHDERMENRL010 Categories: , , , ,

Dermatology Enrollment Form

The Dermatology Enrollment Form is for pharmacies to offer prescribers who diagnose patients with psoriasis or eczema.

The form is easy to fill out online or in print format.

The following drugs are available to quickly prescribe on the form:

  • Cosentix 150mg, 300mg Pen & PFS, and
  • Dupixent 300mg/2mL, and
  • Enbrel 25mg/50mg Sureclick, Prefilled, Mini Cartridge, and Vials, and
  • Erivedge 150mg, and
  • Humira starter & 40mg pen and prefilled, and
  • Odomzo 200mg caps, and
  • Otezla starter, 30mg tabs, and
  • Siliq 210mg prefilled, and
  • Simponi 50mg, Smartject, PFS, and
  • Stelara 45mg, 90mg, and
  • Tremfya TM 100mg prefilled, and

The form is available for download after purchase as an Adobe PDF document, and it is interactive.

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