Please complete the fields below to create your account. All fields are required.
YOUR EMAIL ADDRESS WILL BE YOUR USERNAME
Security Question *
What elementary school did you attend?
What was your dream job as a child?
What was your high school mascot?
In what city were you born?
What is your favorite TV show?
What color was your first car?
What is your spouse's mother's maiden name?
What is your oldest sibling's middle name?
To verify human identity, please type the characters you see into the box below.
Can't Read It? Click Below
Paragard® is a registered trademark, Paragard Access Solutions™ and Paragard Patient Direct™ are trademarks, and Paragard Benefits VerificationSM and Paragard Specialty PharmacySM are service marks of Teva Women´s Health, Inc.
After you've downloaded the Patient Authorization Form, click here to electronically sign it.
Print and have your patient complete the form.
Fax it to 1-855-215-5315
Email it to email@example.com
You can complete the Patient Referral Form in one of the following ways:
Online form:Log in and click the "Refer New Patient" tab to access the online form.
Printed form:Print and complete the form.
Your Patient's Benefits Verification Report will be delivered within 1-2 business days.
Print and complete the form.On the bottom, be sure to check the box next to "Paragard® T 380A Qty: 1".
Upon receipt of your completed forms, we will send you written confirmation via fax.