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Patient Assistance Information

 
1 Program for Dysport injection
 
 
Ipsen Cares Patient Assistance Program

120 Wesrton Oaks Court
Cary, NC 27513
Phone : 866-435-5677
Fax: 888-525-2416
Eligibility
> The Ipsen Cares Patient Assistance Program provides brand name medications at no or low cost and is intended for patients that have no prescription coverage for the needed medication. Medicare Part D patients are not eligible. No residency requirements have been specified. Patient must be diagnosed with severe Primary IGFD.
Who Can Apply
> Patients or doctors can call or print the applications below.
Required
> Application must be completed and signed by the doctor and the patient. Required documents must be attached and sent with the application.
Supply
> Not specified.
Ship To
> Medication will be shipped to the patient's home unless otherwise specified.
Note
>
 
Includes Support for This Drug
NOTE: Linked drugs are available for Prescribers to Apply Online now.
Click drug logo or drug name to start online application.
 
Dysport injection
 
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
 
Download printable Form
Download printable Form
Download printable Form
Download printable Form
Download printable Form
Download printable Form
(Requires Acrobat Reader