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Ordering

Account Setup

To set up your account, we have to collect information to get
you enrolled, including your physical signature.

Please download the appropriate form below, fill it out,
and fax it in to 877.329.6737.

If you don't have Adobe® Acrobat Reader® installed,
please go to the website and download it for free.

NEW TO THE PROGRAM

I have never used LUCENTIS Direct. I'd like to create an account.
Download the form
and fax it in.
LUCENTIS Direct New
Account Setup 605K

ORDERED BEFORE, BUT NEW TO ONLINE ORDERING

I have a LUCENTIS Direct account and have ordered through the phone. I'd like to set up online ordering.
Download the form
and fax it in.
LUCENTIS Direct
New Online Account
Setup 155K

ADDRESS CHANGE

My address has changed since I first joined the program. I'd like to update my address.
Download the form
and fax it in.
LUCENTIS Direct Address
Change Form 124K

ORDERING AGAIN?

Click here to order online.