Medical Information Request (MIR)

First Name

Last Name

Email Address

Credentials

NPI

Institution

Address

City

State

Zip

Preferred Contact Method

Phone

In-Office (MSL visit)

Phone Number

Therapeutic Area

Describe in detail the specific Question or Request

If yes, has the adverse event been reported?

Yes

I requested this information independently and solely for my own evaluation and application to my practice, patients or general education, or the pharmacy and therapeutics committee. I understand that in order to respond appropriately to my question or request for information there may be information related to uses not approved by the FDA distributed to me in response.

Telephone number for US Medical Information call center: 866-773-5274

Sobi Medical Information mailbox: medinfo.us@sobi.com