Name of requester*

First Last

Company or Facility Name of requester*

Position or Title of Requester

Email of Requester*

Phone of Requester

How did Requester hear about Avazzia?

Requester prefers the material to be provided (check preference)

electronically (Bibliography only)
printed and mailed (mailing address required)
both electronically and printed and mailed

Requested clinical research information has

already been delivered to Requester.
has not been delivered. Avazzia is to send information to the Requester.

Business mailing address of Requester

Mailing address is required if material is to be printed and mailed.

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

I understand that the U.S. FDA restricts the dissemination of clinical study reports that present information about new or uncleared claims to health care professionals.*

Yes, I understand that the U.S. FDA restricts the dissemination of clinical study reports that present information about new or uncleared claims to health care professionals.
Yes, I understand that information is not to be used for promoting new or uncleared uses.
I confirm that no promotional materials have been attached to or added to clinical research material provided in response to the request.
I confirm that the clinical research information was not modified, changed, or otherwise changed.

Updates to Clinical Research information requested*

Requester asks to be sent new or updated information about clinical research with Avazzia as it becomes available.
Requester asks not to be sent new information or updated clinical research materials.

Please provide Email of sales representative or value-added reseller that recieved the request for clinical research information on Avazzia.

Name of sales representative or value-added reseller that recieved the request for clinical research information on Avazzia.

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