Medical Information Request | Boehringer Ingelheim

Medical 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 One Mr Mrs Miss Ms Mx Dr RPH PharmD

First Name *

Last Name *

Email *

Inquiry Details

Please provide the requested information.

Inquiry Options *
Select One 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 I would like information on financial assistance I have a request related to samples I have training/demonstration device request I would like to have a sales rep visit I have a question about something else Select One

Product *
Select One Aptivus® (tipranavir) Capsules Atrovent® HFA Inhalation Aerosol Combivent® Respimat® Cyltezo® Gilotrif® Tablets Glyxambi® Tablets Hernexeos® Tablets Jardiance® Tablets Jascayd® Tablets Jentadueto® Tablets Jentadueto® XR Tablets Micardis® HCT Tablets Mirapex ER® Extended-Release Tablets Ofev® Capsules Pradaxa® Capsules Pradaxa® (dabigatran etexilate) Oral Pellets Praxbind® Injection Spiriva® HandiHaler® Spiriva® Respimat® Stiolto® Respimat® Striverdi® Respimat® Synjardy® Tablets Synjardy® XR Tablets Tradjenta® Tablets Trijardy® XR Tablets Other

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

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Lot Number

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

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 One Email Phone Mail

Phone

Country *
Select Country United States Puerto Rico/Virgin Islands

Mailing Address

Please provide the requested mailing address information.

Address 1 *

Address 2

Postcode/ZIP *

City *

State/Territory *
Select One Alabama Alaska American Samoa Arizona Arkansas Armed Forces Americas Armed Forces Pacific California Colorado Connecticut Delaware District of Columbia Federated States of Micronesia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

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 one Alabama Alaska American Samoa Arizona Arkansas Armed Forces Americas Armed Forces Pacific California Colorado Connecticut Delaware District of Columbia Federated States of Micronesia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

Pharmacist/Contact at Pharmacy

Pharmacy/Pharmacist Phone Number

Role/Position *
Select one Patient/Caregiver Doctor of Veterinary Medicine Pharmacy Technician Registered Dietician Physician Osteopathic Physician PharmD Nurse Practitioner Physician Assistant Doctor of Podiatry Medicine Doctor of Dental Surgery Registered Pharmacist Registered Nurse Registered Respiratory Therapist Doctor of Philosophy Master of Public Health Student Other

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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