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Tailored Affordability Support
In case your doctor has given you a 6-letter code, enter it here
Patient’s data
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Last name *
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Date of birth*
Province*
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Document type*
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Caregiver information
Caregiver name*
Caregiver last name *
Caregiver kinship*
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Caregiver gender*
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Document type*
Caregiver document number*
Caregiver email
Caregiver mobile number*
Caregiver's Mobile/Cell Phone
I accept the
sworn declaration
of tailored affordability support.
I accept the
Terms and conditions
of the current program.
I accept the
Informed consent
of the current program.
