Enroll for My ARYMO® ER Patient Savings Program

Please fill in the following information. The information you provide below will be used to sign you up for the My ARYMO® ER Patient Savings Program and send you additional communications about ARYMO® ER

By providing the following information and registering, you are acknowledging that you understand that the information you provide may be used by Egalet, its affiliates, and the business service companies working with Egalet to provide you with additional communications and to develop products and services.

Egalet respects your interest in keeping your personal health information private. We will not sell or rent your information to any third parties or outside mailing lists. For more information on our use of information see our Privacy Statement.

Contact Information

* required

Are your prescriptions paid for in part or full under any state or federally funded program? Such programs include, but are not limited to, Medicare or Medicaid, Medigap, VA, DOD, or TriCare. *
If you begin receiving prescription benefits from such a state, federal, or government funded program at any time, you will no longer be eligible to participate in this program. Do you acknowledge your agreement with this statement? *
Do you have commercial insurance? *
Confirm you are at least 18 years of age *
Are you a resident of the US?*