CSL Behring - Request Medical Information

This form is intended for healthcare professional use only.

If you are a patient or caregiver and would like to request information about CSL Behring products, please contact your health care professional.

If you have encountered any side effect(s) to a CSL Behring product, we encourage you to talk to your doctor, pharmacist, or nurse.

I certify that I am a healthcare professional

Medical Information Request

CSL Behring Product

Describe the Request

HCP Name

Professional Designation

I certify that I am a healthcare professional and that this request was initiated by me. I understand that the information I have provided will be used by CSL Behring and/or its contracted third parties to contact me with relevant information.

Contact Information

How would you like to hear from us?

Email Address

Street

City

State

Zip Code

Phone Number

Fax

You may also request contact from a Medical Science Liason (MSL)

Yes, I would like to be contacted by an MSL

Healthcare Professional Information

Facility Name*

Facility Address 1*

Facility Address 2 (optional)

Facility City*

Facility State*