Supplemental Information for JYNARQUE® (tolvaptan)
Prescriber forms
JYNARQUE Prescription Process Checklist
A reminder of the steps to prescribe patients JYNARQUE.
Prescription Referral Form
You can e-prescribe or fax this completed form to one of the Specialty Pharmacies.
JYNARQUE REMS Program Patient Status Form
Document the required monitoring for patients treated with JYNARQUE.
JYNARQUE Patient Tracker
Record your patients’ monitoring information.
Patient forms
Patient enrollment form
Sign patients up for the REMS program by completing the healthcare professional section first, then having patients fill out the rest. Submit the form either online at JYNARQUEREMS.com or by printing a paper copy that can be submitted by fax at 1-866-750-6820.
Looking for more information about JYNARQUE?
To learn more about JYNARQUE and access more treatment resources, go to JYNARQUEhcp.com.
To learn more about the JYNARQUE REMS program or to access patient forms, go to JYNARQUEREMS.com.