SCENESSE® Patient Registration - SCENESSE® (Afamelanotide)

CLINUVEL is committed to facilitating treatment access for eligible patients with a
confirmed diagnosis of erythropoietic protoporphyria (EPP).

By completing the form below, you will be registered to receive additional information about SCENESSE®

Check your eligibility

To receive further information, and determine your eligibility for the SCENESSE^® Treatment, please answer the following questions (please note further terms and conditions apply):

(If you have been provided with login details by CLINUVEL, you can login here.)

Scenesse Support registration form

Do you have a confirmed diagnosis of erythropoietic protoporphyria?

Yes

No

Are you over the age of 18?

Yes

No

Are you a current resident of the 50 US states, District of Columbia, Guam, Puerto Rico or the Virgin Islands?

Yes

No

Based on the information provided, you are not eligible for this program. Please contact us to be kept up to date on other programs.

Title

Email

First Name

Last Name

Address (PO Box not accepted)

Address Line 1

Address Line 2

City

State

Zip Code

Date of Birth

Primary Care Provider

Phone Number

I confirm that the information I have provided is accurate and complete, to the best of my knowledge. I understand that this information will be used by CLINUVEL, INC., and/or its affiliates or third parties engaged by CLINUVEL to contact me in order to evaluate and facilitate my participation in the SCENESSE® Savings Program. This information will be stored by CLINUVEL, INC. in line with its global privacy policy, available on the www.clinuvel.com website.

If you have been provided login information from CLINUVEL, please enter it below.

Check your eligibility

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