Home > Axona Cares > Enrollment Axona Cares enrollment form Please complete the information below to experience all the benefits that come from being part of the Axona Cares support program. First name* Last name* Email address* Street address* City* State* - Select a state -AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP code* Phone How did you hear about Axona?*Please select oneMy doctorReferral from friendWeb searchNews articleOnline advertisementPrint advertisementMailerOther Please send me a free Axona shaker cup and daily planner Please send me refill reminders When does your loved one begin his or her next prescription? (MM/DD/YYYY) The timing of your refill reminder depends on where the Axona prescription was filled. Please select one of the following: I filled the Axona prescription with a retail pharmacy (reminder at 30 days) I filled the Axona prescription with Brand Direct Health (reminder at 90 days) *Required information.