Saizen Connect

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Patient Details:

Patient Name*

Patient date of birth:*

This patient is new to treatment with SAIZEN*

Yes

Contact details:

If appropriate, please supply caregiver details if they will be main contact:

Patient (or Caregiver) mobile number:

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Patient (or Caregiver) does not have a mobile number

Alternative number:

Patient (or Caregiver) email:

Patient (or Caregiver) confirm email:

Please select the injection device used with SAIZEN*

Serial or lot number*

(?) Show me where I can find the device serial number

I give consent that my details may be used by Merck Healthcare Pty Ltd to contact me as a part of this SAIZEN CONNECT patient support programme - See more information here.

If you have any questions about your treatment with SAIZEN or your injection devices, please call the SAIZEN CONNECT patient services team on 1800 724 936 (9am-5pm AEST Monday to Friday).

To enter this website, you must be enrolled in the SAIZEN^® CONNECT patient support programme.

Sign up to the SAIZEN CONNECT patient support programme by checking the YES option below. You will be contacted by a member of the SAIZEN CONNECT team.

Patient Details:

Contact details:

To login to this website again, please use the same email address above.

To enter this website, you must be enrolled in the SAIZEN® CONNECT patient support programme.

Sign up to the SAIZEN CONNECT patient support programme by checking the YES option below. You will be contacted by a member of the SAIZEN CONNECT team.

Patient Details:

Contact details:

To login to this website again, please use the same email address above.

To enter this website, you must be enrolled in the SAIZEN^® CONNECT patient support programme.