Use this online form or its PDF format to share relevant information with us so that we can contact the patient promptly.

1. Patient informations

Contact person (if other than the patient)

Does the patient have insurance?

2. Documents to attach

Please attach a copy of the prescription (mandatory), the pharmacological profile, or any other relevant information
This field is invalid

3. Pharmacist information

Other comments

The form was successfully sent to us!

Thank you for your cooperation! A pharmacist will call you back within the next 24 business hours to schedule the patient’s specialized treatment.

Keep up to date with our latest news and receive exclusive content for healthcare professionals.

You are a healthcare professional and have questions?

We're here to help.