Request/Report

Healthcare Professionals

I would like to: (Check all that apply)

Request samples.

Request contact from a Primus representative.

Report an adverse event.

For Sample Requests please provide a fax number to allow us to provide a sample request form for signature. A signature is required before we can send samples.

Required fields are bold.

State License Number

Expiration Date (mm/dd/yy)

First Name

Last Name

Address

City

State

Zip

Phone

Fax

Designation:

MD
DO
DPM
NP
PA
Other

Specialty

Anesthesiology	Cardio Disease	Critical Care Med
Emergency Med.	Endocrinology.	Family Practice
General Practice	Geriatrics	Internal Med.
Neurology	OB/GYN	Occupa. Med.
Ortho. Sports Med	Ortho. Surg.	Pain Mgmt
Physical Med.	Podiatry	Rheumatology
Other

How many osteopenic/osteoporotic patients do you see per week?

How many prescriptions do you write per week for osteopenia?

How many prescriptions do you write per week for osteoporosis?

Comments/Report an Adverse Event

Please email someone I know with Fosteum information:

Name 1

Email 1

Phone 1

Physician

Patient

Name 2

Email 2

Phone 2

Physician

Patient

Name 3

Email 3

Phone 3

Physician

Patient

Name 4

Email 4

Phone 4

Physician

Patient

Last modified on 09-27-2007