Supplemental Information for JYNARQUE® (tolvaptan)

Prescriber forms

JYNARQUE Prescription Process Checklist  
A reminder of the steps to prescribe patients JYNARQUE.

Prescription Referral Form  
You can e-prescribe or fax this completed form to one of the Specialty Pharmacies.

JYNARQUE REMS Program Patient Status Form  
Document the required monitoring for patients treated with JYNARQUE.

JYNARQUE Patient Tracker  
Record your patients’ monitoring information.

Patient forms

Patient enrollment form 
Sign patients up for the REMS program by completing the healthcare professional section first, then having patients fill out the rest. Submit the form either online at or by printing a paper copy that can be submitted by fax at 1-866-750-6820.

Looking for more information about JYNARQUE?

To learn more about JYNARQUE and access more treatment resources, go to

To learn more about the JYNARQUE REMS program or to access patient forms, go to