# General Information Request

## Note: This form should not be used to report adverse events for any Boehringer Ingelheim product. Report an Adverse Event by calling  1-800-542-6257 \[TTY: 1-800-459-9906\]

### Personal Information

Please provide the requested information.

Salutation \*

Select OneMrMrsMissMsMxDrRPHPharmD

First Name \*

Last Name \*

Email \*

### Inquiry Details

Please provide the requested information.

Inquiry Options \*

Select OneI would like product or medical informationI would like information on product availabilityI would like information on clinical trialsI have a product complaintI would like more information on Early Access TreatmentsI would like information on financial assistanceI have a request related to samplesI have training/demonstration device requestI would like to have a sales rep visitI have a question about something elseSelect One

- 1\. Product/Medical Information and Availability:
  - I would like product or medical information
  - I would like information on product availability
  - I would like information on clinical trials
  - I have a product complaint
  - I would like more information on Early Access Treatments
- 2\. Financial assistance:
  - I would like information on financial assistance
- 3\. Samples and Demonstrations:
  - I have a request related to samples
  - I have training/demonstration device request
  - I would like to have a sales rep visit
- 4\. Other:
  - I have a question about something else

Product \*
Select OneAptivus® (tipranavir) CapsulesAtrovent® HFA Inhalation AerosolCombivent® Respimat®Cyltezo®Gilotrif® TabletsGlyxambi® TabletsHernexeos® TabletsJardiance® TabletsJascayd® TabletsJentadueto® TabletsJentadueto® XR TabletsMicardis® HCT TabletsMirapex ER® Extended-Release TabletsOfev® CapsulesPradaxa® CapsulesPradaxa® (dabigatran etexilate) Oral PelletsPraxbind® InjectionSpiriva® HandiHaler®Spiriva® Respimat®Stiolto® Respimat®Striverdi® Respimat®Synjardy® TabletsSynjardy® XR TabletsTradjenta® TabletsTrijardy® XR TabletsOther

Upload a clear photo of the product issue to assist with your complaint (Max. 2 photos).

**Allowed extensions:** .jpg, .png, .jpeg

Choose file

Lot Number

[How to find the Lot Number](https://pro.boehringer-ingelheim.com/us/bi-druginforequest/lot-number-help "How to find the Lot Number")

I have insurance

I do not have insurance

Clinical Trial Number

To find the clinical trial numbers, please visit: [https://pro.boehringer-ingelheim.com/us/medinfo/clinical-trials](https://pro.boehringer-ingelheim.com/us/medinfo/clinical-trials "https://pro.boehringer-ingelheim.com/us/medinfo/clinical-trials")

At Boehringer Ingelheim, we understand the importance of providing treatment options for patients with high unmet needs suffering from chronic, debilitating or potentially life-threatening illnesses.

Our unique user-friendly platform is designed specifically to address individual patient requests that fall outside the scope of regular treatment options.

If you are a Healthcare Professional interested in learning more about our platform and how it addresses individual patient requests beyond the scope of regular treatment options, please [**click here**](/content/us/science-innovation/human-health-innovation/clinical-studies/expanded-access-programs "click here"/index.html)

Preferred Method of Response \*

Select OneEmailPhoneMail

Phone

Country \*

Select CountryUnited StatesPuerto Rico/Virgin Islands

### Mailing Address

Please provide the requested mailing address information.

Address 1 \*

Address 2

Postcode/ZIP \*

City \*

State/Territory \*

Select OneAlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming

### Additional Details

Please provide the requested information.

Inquiry Text \*

Servicing Wholesaler, if available

NDC(s) affected \*

Company Name \*

Company Address \*

Company Zip \*

Company City \*

Company State \*
Select oneAlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming

Pharmacist/Contact at Pharmacy

Pharmacy/Pharmacist Phone Number

Role/Position \*
Select onePatient/CaregiverDoctor of Veterinary MedicinePharmacy TechnicianRegistered DieticianPhysicianOsteopathic PhysicianPharm DNurse PractitionerPhysician AssistantDoctor of Podiatry MedicineDoctor of Dental SurgeryRegistered PharmacistRegistered NurseRegistered Respiratory TherapistDoctor of PhilosophyMaster of Public HealthStudentOther

Practice Name/Company/Institution \*

Please read the following consent statement carefully, and check the box below if you agree:

I consent to Boehringer Ingelheim collecting and processing my personal information provided in this form for the purpose of better assisting me and addressing my inquiry. I understand that this information may be imported into Boehringer Ingelheim's CRM system to provide more personalized support and to improve the quality of our services.

I acknowledge that I have the right to withdraw my consent at any time by contacting Boehringer Ingelheim directly.

By checking the box, I confirm that I have read and understood the above consent statement, and I agree to the processing of my personal information as described.

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