FORTEO ConnectTM Services

Joining FORTEO Connect™ provides access to a team of professionals committed to helping you get off to a good start and supporting you every step of the way with FORTEO® (teriparatide injection).

Please select which options you would like to enroll in by checking the corresponding checkboxes below. By enrolling in any of these services below, you are agreeing to the Terms of Participation and consenting to the collection of your information, inclusive of health information as described in the Privacy Statement and Consumer Health Privacy Notice.

FORTEO® INFORMATION AND INJECTION TRAINING
Learn how to get off to a good start from a Nurse Educator — over the phone — and receive information on the delivery device and FORTEO® related questions.
ONGOING FORTEO® SUPPORT
Get personalized support to help make FORTEO® part of your routine today and through your full course of treatment. We are available anytime you have questions or need assistance.

Patient Information and Consent

Required Information
By providing my telephone number and submitting this form, I agree to receive automated marketing calls and texts from and on behalf of Eli Lilly and Company. I understand that I am not required to provide my number as a condition of receiving goods and services. Message and data rates may apply.

TERMS OF PARTICIPATION AND PROGRAM DISCLOSURES

Your healthcare provider has talked with you about using FORTEO®, an Eli Lilly and Company medicine. FORTEO Connect™ offers personalized support to Patients at no charge and was created to help you have a positive experience as you get started with and use this medicine. By checking the corresponding optional boxes above, you consent to your enrollment into FORTEO Connect™.


As part of your participation in FORTEO Connect™, you understand and authorize Lilly USA, LLC to retain and use your personal information for the purposes described in this form. Eli Lilly and Company, Lilly USA, LLC and its affiliates, agents, representatives, and service providers (together “Lilly”) may use, disclose, and/or transfer the personal information you supply to provide services related to your condition and treatment to administer the program.


The FORTEO Connect™ Support team can contact you by email, mail or telephone to provide personalized services and information and materials directly related to your condition and therapy; responding to customer service requests and/or questions about your treatment; disclosing your enrollments and use of these services to your doctors and insurers; analyzing and/or measuring program performance and program effectiveness for future enhancements; and other activities related to your condition and therapy that are part of FORTEO Connect™. Your personal information, including information that may be related to your health, is needed to fulfill your request. To cancel your participation in the program, please contact us at 1-866-FORTEO (1-866-436-7836) Mon-Fri, 8am - 10pm ET. For more information about Lilly's privacy practices, please view the Privacy Statement (https://privacynotice.lilly.com) and the Consumer Health Privacy Notice 
(https://www.lillyhub.com/legal/lillyusa/CHPN.html).


By submitting, I agree and certify that I am at least eighteen (18) years of age or that I am an individual authorized to act on behalf of the Patient in accordance with state law.



PP-TE-US-1143 04/2024 ©Lilly USA, LLC 2024. All rights reserved. 

FORTEO® is a registered trademark and FORTEO Connect™ is a trademark owned or licensed by Eli Lilly and Company, 
its subsidiaries, or affiliates.

Need help with this form? Call FORTEO Connect™ at 1-866-4-FORTEO (1-866-436-7836)


Contact Information