Full Prescribing Information Medication Guide

FORTEO Connect^TM 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 one or both of the following FREE support services:

Forteo Information And Injection Training Ongoing Forteo Support

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

First Name

Last Name

Date of Birth (MM/DD/YYYY):

Gender:

MaleFemale

Primary Language Spoken:

EnglishSpanishOther

Other Language Spoken:

Address:

City:

State:

ZIP Code:

Email:

Phone:

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 purchase. Message and data rates may apply.

What to Know About FORTEO Connect^™:

Your Healthcare Provider has talked with you about using FORTEO^®, an Eli Lilly and Company medicine. FORTEO Connect^™ was created to help you have a positive experience as you get started with and use this medicine. FORTEO Connect^™ offers personalized support to Patients at no charge.

Ongoing Support Enrollment Consent:

The Ongoing Support Services included in FORTEO Connect^™ provide support after you’ve received your medication, like check-in calls to answer any questions you might have about FORTEO^®. As part of your participation in the Ongoing Support Services, Eli Lilly and Company and 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.

Services include:

Contacting you by email, mail or telephone to provide personalized services, delivered by your FORTEO Connect^™ team, such as information and marketing materials; responding to customer service requests and/or questions about your treatment; requesting feedback on your experience with the related products, services, and programs, including market research and medical research; disclosing your enrollment 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 not part of FORTEO Connect^™. These activities include opportunities to share your story and participate in studies about products and services. 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 practice, please view the Privacy Statement.

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.

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

FORTEO ConnectTM Services

Patient Information and Consent

FORTEO Connect^TM Services