Prescriber Enrollment Form - Thank You Page

Prescriber Enrollment Form

Patient Enrollment Form

Prescribers

XYWAV Prescription Form

XYREM Prescription Form

XYWAV and XYREM Prescriber Brochure

2 Patient Enrollment

OPTION 1

If you begin patient enrollment online, your patient will receive an e-mail to complete their portions of the form, including an e-signature. Then, you will electronically submit the form to the XYWAV and XYREM REMS. Both you and your patient will…

You have successfully initiated your Patient Enrollment Form processing. The remainder of the process will be completed via email through DocuSign.

Remind your patient to check their email for a message from DocuSign to complete the enrollment process. When the Patient has signed the form, the Prescriber will receive an email from DocuSign for completion.

Please do not re-submit this…

1 Prescriber Certification

To become certified, each prescriber must complete a XYWAV and XYREM REMS Prescriber Enrollment Form once and submit it to the XYWAV and XYREM REMS via one of the options below. Before enrolling in the XYWAV and XYREM REMS, ensure you’re familiar by reviewing the resources here:…