Registration

Do you have polycythemia vera (PV) and are not being helped by or cannot tolerate hydroxyurea? Are you living with intermediate or high-risk myelofibrosis (MF)? Do you care for someone who does? Register today!

To register, please fill out the form below. By getting to know you a little better, we can provide you with more personalized information and support resources.

Getting to know you

  • Please answer the next few questions
  • You can elect whether or not you want to receive additional information at the end of this section
Thank you!
Please select the types of materials and information that you are interested in receiving:
Myelofibrosis (MF)
Polycythemia vera (PV)

What is your relationship to the person living with MF or PV?
I am that person
I am a family member, friend, or caregiver

Has the Healthcare Professional prescribed Jakafi for you/your loved one's MF or PV?
Yes
No


*Indicates a required field Click here for our Privacy Policy

*First Name:
*Last Name:
Title:
Gender:
*E-mail:
*Confirm E-mail:
*Phone:
*Date of Birth:
*Address 1:
Address 2:
*City:
*State:
*ZIP Code:
How long ago were you, or the person you care for, diagnosed with MF or PV?
Select the resource(s) about Jakafi and MF that interest(s) you:
Patient/doctor discussion guide
Frequently asked questions
Brochure about Jakafi
Patient stories and videos
Myelofibrosis (MF) glossary
Select the resource(s) about Jakafi and PV that interest(s) you:
Brochure about Jakafi
How did you hear about Jakafi.com? (Check all that apply.)
Doctor or other healthcare professional
Magazine/newspaper
E-mail
Mail
Friend or family member
Internet search
Other
General Terms and Conditions

Jakafi patients registering at this site will be enrolled in the IncyteCARES Program. I understand that the personal information I provide on this website may be used by Incyte Corporation, or other companies acting on its behalf, to contact me via mail, via telephone, in electronic format, via Internet-based delivery, or otherwise in the future. I authorize my healthcare providers (eg, physician, pharmacist) and my insurance company to disclose personal health information about me to Incyte, its agents, and IncyteCARES. Incyte, its agents, and IncyteCARES may contact me and use and release information about me only for the purposes of (1) assisting in my enrollment in IncyteCARES; (2) assessing my eligibility for copay assistance or free drug or referring me to other programs or sources of funding and financial support; (3) coordinating delivery of Jakafi® (ruxolitinib) to me or my healthcare provider; (4) providing education and ongoing support services to me related to Jakafi, myelofibrosis (MF), and other areas of interest; and (5) gathering feedback on the disease/treatment. I understand that some of my information may be provided anonymously and used in an individual or aggregated form for other legitimate purposes by Incyte. I understand that reasonable efforts will be made to keep my information private even though some of my information that is redisclosed under this authorization may no longer be protected under federal and state privacy laws. Any copay assistance or free drug provided to me through IncyteCARES is contingent upon meeting certain eligibility criteria, and Incyte may, at any time and without notice, modify or discontinue IncyteCARES or any assistance provided directly to me. I understand that I do not have to sign this authorization to obtain treatment or seek payment for treatment on my own; however, to be eligible for the services provided by Incyte and IncyteCARES, I must sign the authorization. I understand that I may cancel my authorization, or opt out of receiving any of the above services or communications, at any time by contacting IncyteCARES at 1-855-452-5234, by fax at 1-855-525-7207, or by mail at P.O. Box 221798, Charlotte, NC 28222-1798. If I cancel the full authorization, then my healthcare providers and my insurance company will not provide any further information about me, and IncyteCARES will no longer be able to provide me with the assistance, education, or services described above. I acknowledge that I am a resident of the United States and verify that the information provided in this enrollment form is current, complete, and accurate. This authorization expires in ten (10) years.

My personal information may also be used for the purposes described in Incyte's Privacy Policy. I understand that from time to time, Incyte Corporation's Privacy Policy may change and that I should check the website for the most recent version. I understand that I should check the website for the most recent version of Incyte Corporation's Legal Notices.

* I agree to the General Terms and Conditions

Living with myelofibrosis (MF)

Please supply the following information. By telling us about yourself and your experiences with MF, we can provide you with more personalized information and resources.

The following questions are all optional.

Which treatments are you or the person you care for currently receiving for MF? (Select all that apply)
Aspirin
Hydroxyurea
Jakafi

Which treatments have you or the person you care for tried for MF? (Select all that apply)
Aspirin
Hydroxyurea
Jakafi

How do the symptoms of MF affect you or the person you care for on a daily basis?

Thank You for Registering

If you ever have any questions or suggestions, please feel free to contact us.


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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.
 
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.

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.