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Get started with enrollment
Together with ZEJULA offers options to complete enrollment online or through the portal. Either option will take less than 10 minutes to complete.
Help enroll your patients
Choose an option below
Start online or choose another option that works best for you.
Make sure it’s signed
Whether enrolling online or in print, be sure to “sign” (authorize) the form before you send it.
Review and submit
All required fields should be complete prior to submitting the form.
No matter which option you choose, Together with ZEJULA will help your patient as soon as they are enrolled.
Option 1. Enroll online
You are guided through what information is needed to process the enrollment for your patient.
Option 2. Print and fax
If you would like a downloadable form to fill out, click the button below to print it. Fill out the enrollment form and confirm all required fields have been completed. Then fax it to 833-ZEJULA0 (833-935-8520).
We are here to help!
You can reach your Patient Navigator at 1-844-4GSK-ONC (844-447-5662)
Monday–Friday: 8:00 AM – 8:00 PM ET