Medical Information Request Form

To: GALT Medical Affairs
Date: Date: / MM / DD YYYY
From: (HCP Requestor):
Select One:

Select One: Doctor Nurse Pharmacist Other Other
Name Name Title First Last Suffix
Specialty:
Hospital/Institution/Office:
Address: Address:
Street Address Address Line 2 City State / Province / Region Postal / Zip Code
Telephone: Telephone: - ### - ### ####
Fax: Fax: - ### - ### ####
Email Address:
GALT Contact/Sales Rep Name:
Galt Contact/Sales Rep Email Address:
Which product is this inquiry in regard to:

Which product is this inquiry in regard to: Doral (Quazepam) Oravig (Miconazole) Norgesic Norgesic Forte Other
Enter your question(s) of inquiry below:
What is the desired response method(s) of which you prefer to be communicated by?

What is the desired response method(s) of which you prefer to be communicated by? Email Telephone Postal Mail Fax Other Other
Please allow at least 24-48 business hours for a response, but allow at least 72 business hours if literature research and evaluation is required.
Adverse Event Reporting:

Contact our Pharmacovigilance contact at 1-833-757-0904 in case of any adverse event or product quality complaint occurs while using our product and comply with your local regulations for notification.