Product enquiry

Please complete the form below so that our customer services team can respond to your enquiry as quickly as possible.

Fields marked * are mandatory.

Contact details

First name *

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Surname *

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Email *

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Phone *

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Your organisation

Organisation name *

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Postcode *

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Organisation Country *

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Drug Details

Generic name/Active Ingredient *

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Strength & Dosage Form *

Required Quantity *

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Required Target Price

Drug authorisation

Does this product have a Marketing Authorisation in your country?

Yes but is on short supply

Yes but is not being commercialised by its holder

Yes but is going to be discontinued

Yes but I need a specific dose form

* Is this product for a patient with a clinical need which cannot be met by a licensed product in your country?

Yes

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* Please select from the below

I am a healthcare professional

I am a patient or relative of a patient

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