MIR Form – Connect2 – FAR + Medical Affairs

All fields required

For medical information request please fill out the form below and one of our medical affairs representatives will contact you within 48 hours.

First Name*

Last Name*

Professional Designation*

Affiliation*

Address 1*

Address 2

City*

State*

Zip*

Email*

Enter Email Confirm Email

Phone Number*

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What Octapharma product are you inquiring about?*

Please describe your medical inquiry below*

Med Request Checkbox*

I certify this is an unsolicited medical request.

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You may also call Octapharma medical affairs and leave a message at 888-429-4535, or send an e-mail with your unsolicited medical request to usmedicalaffairs@octapharma.com.