ZEMAIRA® | ZEMAIRA Carez Patient Enrollment

Help your interested patients receive the full benefit of ZEMAIRA CareZ^® comprehensive access solutions and support. Get your patient's enrollment started today by completing and submitting the information below.

Prescriber Information

First Name:

Last Name:

Facility Name:

Facility Address Line 1:

Facility Address Line 2 (Optional):

Facility City:

Facility State:

Facility ZIP Code:

Facility Phone Number:

State License Number:

Patient Information

First Name:

Last Name:

Date of Birth:

Gender (Optional): Male Female

Address Line 1:

Address Line 2 (Optional):

City:

State:

ZIP Code:

Phone Number:

Please provide additional information to help personalize your patient's CareZ experience

How long has your patient been taking ZEMAIRA? Newly diagnosed (first time taking ZEMAIRA) Number of years

Before taking ZEMAIRA, what other treatment did your patient take? Prolastin Glassia Aralast NP None

How does your patient prefer to receive information from CareZ? Mail Email Phone All

I attest that I have obtained this patient's prior consent to release the information above and to request direct outreach from ZEMAIRA CareZ. My patient is aware that he/she is not obligated to enroll in CareZ or accept any support offered by CareZ.

Welcome to CareZ Enrollment

Prescriber Information

Patient Information

Please provide additional information to help personalize your patient's CareZ experience