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NexConnect, a free patient-support program from the team that developed Nexavar, provides frequent communications and tools to help you manage your therapy. In addition to the information already provided by your health care team, you'll also have access to a Registered Nurse who can provide you with information regarding your treatment with Nexavar.

Participant Information

* I'm a

 Patient  Caregiver

* First Name

* Last Name

* Street Address

* City

* State

AlabamaAlaskaAlbertaArizonaArkansasBritish ColumbiaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineManitobaMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew BrunswickNew HampshireNew JerseyNew MexicoNew YorkNewfoundlandNorth CarolinaNorth DakotaNorthwest Terr.Nova ScotiaNunavutOhioOklahomaOntarioOregonPennsylvaniaPrince Edward Isl.QuebecRhode IslandSaskatchewanSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingYukonInternational

* Zip

Email Address

* Daytime Phone

* Evening Phone

Cell Phone

Best Time to Call

NexConnect can leave messages on my phone

 Yes  No

Patient Authorization I verify that the information provided in this enrollment form is current, complete, and accurate. I understand Bayer Pharmaceuticals Corporation and Onyx Pharmaceuticals Inc. reserve the right at any time, and without notice, to modify or discontinue the NexConnect Program with respect to any patient (including me), or to modify or discontinue the program entirely.

I authorize the NexConnect Program to use and obtain my protected health information from my prescribing physician, insurance company, specialty pharmacy and other sources as deemed necessary to ensure the accuracy and completeness of this enrollment form, to provide services to me, and to otherwise administer the NexConnect Program.

I authorize Bayer, Onyx and the NexConnect Program to do the following:

• Use and give out my information [to send me information or materials related to Nexavar (or any other related products or services in which I might be interested)]
• Contact me occasionally to get my feedback (for market research purposes) about Nexavar or the NexConnect Program
• Operate (and improve the quality of) the NexConnect Program, or otherwise as required or permitted by law

I acknowledge that I am a legal resident of the United States. I authorize my healthcare providers, insurance companies, and specialty pharmacies to use and disclose to Bayer, Onyx, the NexConnect Program and their authorized agents and assignees, all medical records and financial information with respect to my treatment, my eligibility for assistance, the coordination of my Nexavar treatment (and the receipt of my medication), and my participation in the NexConnect Program for the purposes of providing services to me and otherwise administering the program. I understand that my healthcare providers and insurance company will not modify my medical treatment, payment for treatment, insurance enrollment, or eligibility for insurance benefits on my signing of this authorization. I understand, however, that if I do not sign this authorization, I will not be eligible to enroll in the NexConnect Program.

If I do not wish [to receive information related to Nexavar (or any related products or services) or] to be contacted occasionally for market research purposes, I may call the NexConnect Program's toll-free number: 1.866.NEXAVAR (1.866.639.2827), at any time.

 * I have read and accept the Patient Authorization terms