Factor it Forward IXINITY Request Form

Please use the form below to place your order for Ixinity. Any questions or concerns please contact the Americares US Program at usprogram@americares.org or 203-658-9690

About Factor it Forward

Americares has partnered with Medexus Pharma, the company behind IXINITY [Coagulation Factor IX (Recombinant)], to create a first-of-its-kind factor donation program for Hemophilia Treatment Centers and Blood Collection Centers providing care to people who are uninsured or underinsured and are living with hemophilia B.

Partner Information

Organization Name*

USAccess User ID*

Enter the user ID you use on the Americares USAccess site.

Contact Name*

Contact Email Address*

Best Contact Phone Number*

Delivery Street Address*

City*

State*

Zip Code*

Order Details

Order Date*

Preferred Delivery Day*

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Is this an Urgent Request?

Check box below if this is an urgent request.

What is the nature of your request?*

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Request Reason Detail*

Total # of IU Requested (IXINITY)*

Assay Preference

Please note, we cannot guarantee this request can be fulfilled.

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