Other

Other

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Case Number (i.e. CC-1234567) *

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First Name *

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E-mail *

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Phone Number *

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Institution Name *

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Inquiry Details *

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Attachment(s) *

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First Name *

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Last Name *

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E-mail *

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Phone Number *

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Institution Name *

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Inquiry Details *

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Attachment(s) *

You can only attach up to 10MB Following file extensions are allowed: .xls,.xlsx,.doc,.docx,.ppt,.pptx,.pdf,.msg,.eml,.jpg,.jpeg,.png {{crossValidationError['attachmentNoOpenCaseAnonymous'].crossValidationErrorMessage}}
Is this related to an open case? * *
This is a required field
Please include reports made by the pharmacy or patient for the same product

Case Number (i.e. CC-1234567) *

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First Name *

Please enter your first name

Last Name *

Please enter your last name

E-mail *

Please enter e-mail address Please enter e-mail address

Phone Number *

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Institution Name *

Please enter institution name {{crossValidationError['institutionNameYesOpenCase'].crossValidationErrorMessage}}
Please enter the name of the product {{crossValidationError['productYesOpenCase'].crossValidationErrorMessage}}

Inquiry Details *

Please be as detailed as possible

Attachment(s) *

You can only attach up to 10MB Following file extensions are allowed: .xls,.xlsx,.doc,.docx,.ppt,.pptx,.pdf,.msg,.eml,.jpg,.jpeg,.png {{crossValidationError['attachmentYesOpenCase'].crossValidationErrorMessage}}
* mandatory field

First Name *

Please enter your first name

Last Name *

Please enter your last name

E-mail *

Please enter e-mail address Please enter e-mail address

Phone Number *

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Institution Name *

Please enter institution name {{crossValidationError['institutionNameNoOpenCase'].crossValidationErrorMessage}}
Please enter the name of the product {{crossValidationError['productNoOpenCase'].crossValidationErrorMessage}}

Inquiry Details *

Please be as detailed as possible

Attachment(s) *

You can only attach up to 10MB Following file extensions are allowed: .xls,.xlsx,.doc,.docx,.ppt,.pptx,.pdf,.msg,.eml,.jpg,.jpeg,.png {{crossValidationError['attachmentNoOpenCase'].crossValidationErrorMessage}}
* mandatory field