Product Availability Inquiry Form | Boehringer Ingelheim

Product Availability

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

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Salutation *

Select OneMrMrsMissMsMxDrRPHPharmD

First Name *

Last Name *

Email *

Inquiry Details

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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

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

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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 OneEmailPhoneMail

Phone

Country *

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Mailing Address

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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

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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 *

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