Attestation Form
Completion of Pretests and Assessments
Before initiation of treatment with PONVORY™, assess the following based on individual patient needs:
Complete Blood Count, Cardiac Evaluation, Liver Function Tests, Ophthalmic Evaluation,
Current or Prior Medications with Immune System Effects, and Vaccinations.
Instructions for Prescriber and/or a representative authorized by the Prescriber to sign and act on their behalf (“Authorized Representative”)
1. Please read and sign the attestation below with healthcare provider or authorized representative signature
2. Fax the completed form to 833-200-6306
If the form is not submitted, Janssen CarePath will call you and/or your office for verbal confirmation of completion of pretests and assessments.
Patient Information
Patient Name (First, MI, Last) Date of Birth (mm/dd/yyyy)
By signing this form, I attest that I have assessed the following based on individual patient needs: Complete Blood Count, Cardiac Evaluation,
Liver Function Tests, Ophthalmic Evaluation, Current or Prior Medications with Immune System Effects, and Vaccinations. This patient is
cleared to initiate therapy with PONVORY™.
Please complete and sign Prescriber Information OR Authorized Representative Information:
Prescriber Information
Prescriber Name (Please print) Prescriber NPI Site Phone
Site Name and Address City State ZIP
Prescriber Signature (NO STAMPS ALLOWED)
Date (mm/dd/yyyy)
OR
Authorized Representative Information
Authorized Representative Name (Please print) Authorized Representative Title
Prescriber Name (Please print) Prescriber NPI Site Phone
Site Name and Address City State ZIP
Authorized Representative Signature
(NO STAMPS ALLOWED)
Date (mm/dd/yyyy)
First dose monitoring is (please check one):
Required. I confirm I have counseled my patient on first dose monitoring requirements as described in the Prescribing Information. Please ship to the
address below.
Not Required. Janssen CarePath will ship to the site or patient address you provided previously on the Prescription Enrollment Form. If that address is
no longer valid, please provide an updated site or patient address below and Janssen CarePath will ship to this address instead.
Ship to address:
Site Name (or Patient Name) Site Contact (if applicable) Phone
Address City State ZIP
tablets
Please see full Prescribing Information and Medication Guide for PONVORY™.
Provide the Medication Guide to your patients and encourage discussion.
© Janssen Pharmaceuticals, Inc. 2021 6/21 cp-208128v2
