Mentee Registration Form


Everyone’s journey with polycythemia vera and myelofibrosis is different

Because polycythemia vera (PV) and myelofibrosis (MF) are rare, chronic blood cancers, you and other patients or caregivers may feel alone or isolated from a support community where you can talk about common experiences.

Now you can register to talk with a patient who is taking Jakafi®. The Incyte Mentor Program is for people living with PV who have already taken hydroxyurea (HU) and it did not work well enough or they could not tolerate it, people with intermediate or high-risk MF, or their caregivers.

Through supportive, informative phone calls, the program provides the opportunity to connect with a mentor* who is currently taking Jakafi.

*Mentors are volunteers and do not give medical advice. It is important to talk to your Healthcare Professional for all questions about your health and medical condition.


Register to talk with a patient taking Jakafi

To participate in a conversation about your journey with PV, MF, or Jakafi, please complete and submit the form below. By registering, you are confirming that you are an appropriate participant for this program. A program representative will contact you for more information.

Please complete the following fields.
All fields are required unless otherwise marked.

Your Details
First Name
Last Name
I am a:


Your Contact Information
Email Address
Phone
Best time of day to call (Optional)
Permission to leave a voicemail
Medical Information
How long ago were you, or the person you care for, diagnosed with PV or MF?
Has a Healthcare Professional prescribed Jakafi for you/your loved one’s PV or MF?
Consent for Use of Personal Information

By clicking “SUBMIT” below, I authorize Incyte Corporation (“Incyte”) and its agents to use my registration information provided above (my “Information”) to contact me in order to (i) provide education and ongoing support services to me related to treatment, disease and other areas of interest; (ii) provide information about Incyte products and services; and (iii) provide company updates about Incyte. I understand that I may at any time revoke my consent to be contacted for any of these purposes by “opting out” by calling the Incyte Mentor Program at 1-877-647-9206 or emailing info@IncyteMentorProgram.net.

I also authorize Incyte and its agents to (i) combine my Information with that of other registrants to create aggregated, anonymized data and to use and share the anonymized data for any legitimate purpose; and (ii) to use and disclose my Information for any other purpose described in Incyte’s Privacy Policy. I understand that Incyte’s Privacy Policy may change from time to time and that I should check the website for the most recent version, as well as for the most recent version of Incyte’s Legal Notices.

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Important Safety Information

Indications and Usage

Jakafi is a prescription medicine used to treat people with polycythemia vera who have already taken a medicine called hydroxyurea and it did not work well enough or they could not tolerate it.

Jakafi is also used to treat certain types of myelofibrosis.

Important Safety Information

Jakafi can cause serious side effects, including:

Low blood counts: Jakafi® (ruxolitinib) may cause your platelet, red blood cell, or white blood cell counts to be lowered. If you develop bleeding, stop taking Jakafi and call your healthcare provider. Your healthcare provider will perform blood tests to check your blood counts before you start Jakafi and regularly during your treatment. Your healthcare provider may change your dose of Jakafi or stop your treatment based on the results of your blood tests. Tell your healthcare provider right away if you develop or have worsening symptoms such as unusual bleeding, bruising, tiredness, shortness of breath, or a fever.

Infection: You may be at risk for developing a serious infection during treatment with Jakafi. Tell your healthcare provider if you develop any of the following symptoms of infection: chills, nausea, vomiting, aches, weakness, fever, painful skin rash or blisters.

Skin cancers: Some people who take Jakafi have developed certain types of non-melanoma skin cancers. Tell your healthcare provider if you develop any new or changing skin lesions.

Increases in cholesterol: You may have changes in your blood cholesterol levels. Your healthcare provider will do blood tests to check your cholesterol levels during your treatment with Jakafi.

The most common side effects of Jakafi include: low platelet count, low red blood cell counts, bruising, dizziness, headache.

These are not all the possible side effects of Jakafi. Ask your pharmacist or healthcare provider for more information. Tell your healthcare provider about any side effect that bothers you or that does not go away.

Before taking Jakafi, tell your healthcare provider about: all the medications, vitamins, and herbal supplements you are taking and all your medical conditions, including if you have an infection, have or had tuberculosis (TB) or have been in close contact with someone who has TB, have or had hepatitis B, have or had liver or kidney problems, are on dialysis, had skin cancer, or have any other medical condition. Take Jakafi exactly as your healthcare provider tells you. Do not change your dose or stop taking Jakafi without first talking to your healthcare provider. Do not drink grapefruit juice while on Jakafi.

Women should not take Jakafi while pregnant or planning to become pregnant, or if breast-feeding.

Please see the Full Prescribing Information, which includes a more complete discussion of the risks associated with Jakafi.

You are encouraged to report negative side effects of prescription drugs to the FDA. Visit www.fda.gov/medwatch, or call 1-800-FDA-1088.

You may also report side effects to Incyte Medical Information at 1-855-463-3463.