Healthcare Professional Sign-Up Form

To sign up patients for additional education and support at no extra cost to them, please complete the form below. After signing them up, they can expect a call from a TREMFYA withME Guide within 1 to 2 business days.

TREMFYA withMe is limited to providing information to your patients about their currently prescribed TREMFYA® medication, its administration, and the conditions it is indicated to treat. TREMFYA withMe does not provide medical advice, change your treatment plan, or provide case management services. The information your patients provide will be used by Janssen Biotech, Inc., our affiliates, and our service providers to contact your patients by phone to describe TREMFYA withMe and complete the enrollment process. Our Privacy Policy further governs the use of the information you provide. Your patient may request to discontinue their participation in TREMFYA withMe by calling 1‑833‑948‑4631. By providing your and your patient’s information below and clicking SUBMIT, you indicate that you have read, understand, and agree to these terms.

I confirm that l have a valid HIPAA authorization for this patient that permits me to provide their information for the purposes described above.

Privacy Statement *

Please fill in all required fields.

*Required Fields

Your Information

NPI Number *

Healthcare Professional Email *

Healthcare Professional Phone Number

Healthcare Professional First Name *

Healthcare Professional Last Name *

Your Patient's Information

First Name *

Last Name *

Date of Birth (mm/dd/yyyy) *

ZIP Code *

Phone Number *

Preferred Email Address

What time frame does your patient prefer for receiving a call from their Guide? No worries, their Guide will reach out at their local time regardless of their time zone.

Morning (8:00 AM to 12:00 PM)

Afternoon (12:00 PM to 4:00 PM)

Evening (4:00 PM to 8:00 PM)

No preference

Would your patient prefer to be contacted by a Spanish-speaking Guide?

Yes

Does your patient give their permission for their TREMFYA withMe Guide to leave a voice mail containing their health information?

Yes

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