Somerset VIP Program Enrollment Form

This Enrollment Form is the primary mechanism of enrollment for the Eldepryl V.I.P. Program; completion can be initiated by either the physician or the patient.

Print this form out, fill in all information, and mail to:

The Form must be signed and dated by the patient for enrollment in the program.

Complete the Following:

Patient first name _______________________________________

Patient last name _______________________________________

Address _______________________________________

Phone _______________________________________

City, State Zip _______________________________________

Email Address _______________________________________

Are you currently taking Eldepryl® Capsules, 5mg (selegiline hydrochloride)?
____Yes
____No

If yes, for approximately how long?
____0-3 months
____3-6 months
____6-9 months
____9-12 months
____1-2 years
____over 2 years

Physician Name _______________________________________

Address _______________________________________

City, State Zip _______________________________________

Phone _______________________________________

Physician's Email _______________________________________

I understand that I will receive materials by mail when I enroll in the V.I.P. Program.

Signature__________________________________________
Date______________________________________________

If you no longer wish to receive V.I.P. Program materials, please contact the VIP Patient Program at the address listed above.

Patient first name	_______________________________________
Patient last name	_______________________________________
Address	_______________________________________
Phone	_______________________________________
City, State Zip	_______________________________________
Email Address	_______________________________________

Are you currently taking Eldepryl® Capsules, 5mg (selegiline hydrochloride)? ____Yes ____No If yes, for approximately how long? ____0-3 months ____3-6 months ____6-9 months ____9-12 months ____1-2 years ____over 2 years
Physician Name	_______________________________________
Address	_______________________________________
City, State Zip	_______________________________________
Phone	_______________________________________
Physician's Email	_______________________________________

I understand that I will receive materials by mail when I enroll in the V.I.P. Program.
Signature__________________________________________ Date______________________________________________ If you no longer wish to receive V.I.P. Program materials, please contact the VIP Patient Program at the address listed above.