IRMA4673 (Please, don't change)

Enroll in the Novartis Patient Navigator Program

To sign up for SCEMBLIX Patient Navigator, please fill out the form below, and then click "Submit" when you're finished. You must be 18 years of age or older to participate in this program.

* Required fields.

First name *

Last name *

Date of Birth

Date of Birth Help text

Gender *

Male

Female

Address 1 *

Address 2 *

City *

State *

Select a State

Zip Code *

Five digits only

Telephone Number *

By checking this box, I confirm that I am taking SCEMBLIX for an approved use, consistent with the product's Prescribing Information. See below for approved uses.

I agree to the Terms & Conditions: You consent to receive marketing calls and texts from and on behalf of Novartis Pharmaceuticals Corporation, made with an autodialer or prerecorded voice, at the phone number(s) provided. You understand that your consent is not required or a condition of purchase. Number of messages will vary based on your program selections; average of [3 to 15] messages per week. Message and data rates may apply. The Novartis Pharmaceuticals Corporation Privacy Policy is available at https://www.novartis.com/us-en/privacy-policy-2. Text STOP to opt out and HELP for help.

OK to leave detailed voice mail about your medication on your phone *

Yes

Type of Insurance *

Commercial/Private

Medicare/Medicaid

Uninsured

Consumer Status *

I am taking SCEMBLIX for an approved use, consistent with the product's Prescribing information. See below for approved uses.*

Question text

Survey Text Input Question Help text

By clicking submit, I confirm I’d like to enroll in the Patient Navigator Program, and agree to receive recurring phone calls from a Novartis Patient Navigator at the number(s) provided. Calls may be prerecorded or autodialed. Consent and participation in the Program is not a condition of purchase of a product or service.

Thank you for signing up for the Novartis Patient Navigator Program.

Thank you for registering. A Navigator will be contacting you to confirm your eligibility.

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