COPD Care

Doctor Information

Please provide your doctor's contact information so we can submit your health assessment for review.

* Required Field

Doctor's Last Name

Doctor's First Name

City and State or ZIP

Distance From the City and State or ZIP

Enter Your Doctor's Information

Please provide your doctor's contact information so we can submit your health assessment for review.

Doctor's First Name

Doctor's Last Name

Doctor's City

Doctor's State

Doctor's ZIP

Doctor's Address

Doctor's Phone Number

Personal Information

The following details are required to complete this submission to your doctor.

First Name

Last Name

Address

Apt, Suite or Floor Number

City

State

ZIP

Date of Birth

Sex at Birth

Mobile Number

Email Address

I agree to ASPN pharmacies LLC's Terms of Use and Privacy Policy, and agree that ASPN Pharmacies may (1) use my information to communicate with me about medicines, services and programs, or to provide me with information relation to my healthcare treatment, payment for healthcare, or other health information or care coordination services, in accordance with such terms: and (2) contact me at the phone number and email address set forth above, and use automatic dialing machines, automated, pre-recorded voice messages, and may send SMS/Text messages. I understand that I may opt out at any time by texting "stop" in return to a text or by calling ASPN at 888-898-0545, and that my consent to this contact is not required for the purchase of any medicines. I understand that my service provider's airtime, message and data rates may apply. In addition, I certify that I am the patient referenced above or (ii) am the parent or legal guardian of the patient referenced above, and that I am at least eighteen (18) years of age.

How would you like to proceed? (Check all that apply)

I am interested in discussing COPD medication options that are appropriate for me.

I would like an in-person visit to discuss my health questionnaire.

I am requesting a prescription for BREZTRI AEROSPHERE® (budesonide, glycopyrrolate, and formoterol fumarate) Inhalation Aerosol.

BREZTRI APPROVED USE & IMPORTANT SAFETY INFORMATION

APPROVED USE

BREZTRI AEROSPHERE is a medicine used long term to treat chronic obstructive pulmonary disease (COPD), including chronic bronchitis, emphysema, or both, for better breathing and fewer flare-ups.

BREZTRI is not used to relieve sudden breathing problems and will not replace a rescue inhaler.
BREZTRI is not for the treatment of asthma.

IMPORTANT SAFETY INFORMATION

BREZTRI combines 3 medicines, an inhaled corticosteroid (ICS) medicine (budesonide), an anticholinergic medicine (glycopyrrolate), and a long-acting beta2-adrenergic agonist (LABA) medicine (formoterol fumarate). LABA medicines, such as formoterol fumarate, when used alone can increase the risk of hospitalizations and death from asthma problems. When an ICS and LABA are used together, this risk is not significantly increased
Do not use BREZTRI if you are allergic to budesonide, glycopyrrolate, formoterol fumarate, or any of the ingredients in BREZTRI
Do not take BREZTRI with other medicines that contain a long-acting beta₂-adrenergic agonist (LABA) or an anticholinergic for any reason. Tell your healthcare provider about all your medical conditions and about all the medicines you take
BREZTRI should be taken as 2 puffs, 2 times each day. Do not use BREZTRI more often than prescribed
Call your healthcare provider or get medical care right away if your breathing problems get worse, if you need to use your rescue inhaler more often than usual, or your rescue inhaler does not work as well to relieve your symptoms
BREZTRI can cause serious side effects, including:
- Fungal infection in your mouth or throat (thrush). Rinse your mouth with water without swallowing after using BREZTRI to help reduce your chance of getting thrush
- Pneumonia. People with COPD have a higher chance of getting pneumonia. Call your healthcare provider if you notice an increase in mucus (sputum) production or change in mucus color, fever, chills, increased cough, or increased breathing problems
- Weakened immune system and increased chance of getting infections (immunosuppression)
- Reduced adrenal function (adrenal insufficiency). This can happen when you stop taking oral corticosteroid medicines and start inhaled corticosteroid medicine
- Sudden breathing problems immediately after inhaling BREZTRI. If this happens, stop taking BREZTRI and call your healthcare provider right away
- Serious allergic reactions. Call your healthcare provider or get emergency medical care if you get any of the following symptoms: rash; hives; swelling of your face, mouth, and tongue; or breathing problems
- Effects on your heart such as increased blood pressure, a fast or irregular heartbeat, or chest pain
- Effects on your nervous system such as tremor or nervousness
- Bone thinning or weakness (osteoporosis)
- Acute narrow-angle glaucoma and cataracts. If you have new or worsening eye or vision problems, call your healthcare provider right away before taking another dose
- Urinary retention. If you have new or worsening symptoms or difficulty urinating, stop taking BREZTRI and call your healthcare provider right away before taking another dose
- Changes in laboratory blood values, including high levels of blood sugar (hyperglycemia) and low levels of potassium (hypokalemia). Low levels of potassium may cause symptoms of muscle spasm, muscle weakness, or abnormal heart rhythm
Most common side effects include: upper respiratory tract infection, pneumonia, hoarseness, back pain, thrush in your mouth and throat, flu, muscle spasms, urinary tract infection, cough, inflammation of the sinuses, and diarrhea

Please see full BREZTRI Prescribing Information, including Patient Information.

You may report side effects related to AstraZeneca products .

Please review the information below.

Patient Information

Edit

Name:

Address:

Date of Birth:

Sex at Birth:

Phone Number:

Email:

Doctor Information

Edit

Name:

Phone Number:

Address: