Order OPENINGS® Patient Support Program Starter Kits

Order OPENINGS® Patient Support Program Starter Kits

To request kits, please fill in the fields below. Allow 2-3 weeks for delivery.

Name of Doctor

State License #

Name of Practice

Specialty: Ophthalmologist, Optometrist, Other

Address

Address

City
State
Zip

Ship to the attention of

Phone Number

I consent to receive telemarketing calls from and on behalf of Novartis Pharmaceuticals Corporation and its affiliates, including calls made with an autodialer or prerecorded voice, at the telephone number(s) above. I understand that my consent is not required as a condition of receiving information or materials about the Openings Patient Support Program or purchasing any goods or services from Novartis.

E-mail Address

Confirm E-mail Address

Number of English kits*

By clicking SUBMIT ORDER, I agree to the Novartis Pharmaceuticals Corporation Terms of Use . I understand and agree that the information I provide will be used in accordance with the Novartis Pharmaceuticals Corporation Privacy Policy, including to provide me with marketing information, offers, and promotions and to contact me for my opinions regarding products, programs, and services.

I HAVE READ AND AGREED TO NOVARTIS PRIVACY POLICY.

*Terms and Conditions: Limitations apply. A patient is eligible for this promotion if the commercial health plan co-pay is more than $30 per 30 day supply. For commercially insured patients 16 years or older. Up to a $105 cap per 30 day supply. Patient will be responsible for any co-pay once limit is reached. This offer is not valid under Medicare, Medicaid, or any other federal or state program. Not valid for cash-paying patients. Novartis reserves the right to rescind, revoke, or amend this program without notice. Offer expires 6/30/2018.Click here for full terms and conditions.

 
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