Emend® (aprepitant)

Download the ACT Patient Enrollment Form

You may complete the fields online and print it.
OR
You may print out the form and complete it by hand using a black ballpoint pen.

ACT Patient Enrollment Form (English)
[PDF: 384KB, 3 pages]

To meet your unique needs, there are 3 ways to start the ACT enrollment process: by phone, fax, or mail.

Phone

Simply call 866-363-6379 between 8 am and 8 pm ET, Monday through Friday, and a Program Specialist will begin the enrollment process.

Fax

1. Step 1: Complete and sign the ACT Patient Enrollment Form available above.
   • You must complete all sections on the enrollment form.
   • Both you and your doctor must sign the enrollment form.
   • Enrollment forms that are incomplete or incorrect will slow down the processing of your request.

Step 2: Fax your completed enrollment form to 866-363-6389.

Please note: Your doctor must fax your prescription for EMEND directly to ACT.

Mail

If you do not have access to a fax machine, you may mail the signed original ACT Patient Enrollment Form and your prescription for EMEND to the address below:

ACT
PO Box 18979
Louisville, KY 40261-0979

If you meet the eligibility criteria, your capsules of EMEND will be shipped 2-3 business days after we receive your completed enrollment form and your prescription for EMEND.