Merck Patient Assistance Program - Request a Brochure and Application On-Line

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Request a Brochure and Application On-Line

Patients/Consumers:
In order to provide you with an application for the program, you must be a resident of the United States, Puerto Rico, Guam, or the US Virgin Islands. Although people of all ages, if eligible, can participate in the program, the information can only be sent to persons 18 years of age or older.

Please fill out all required fields below.

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Please read our privacy policy to learn about how Merck protects your personally identifiable information.

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Request a Brochure and Application On-Line

Global Health

Unbiased Health Information