EAP – Helsinn

Compound*

Disease / condition to be treated*

Physician information

Name*

Title First Name Last Name

Institution (if any)

Address*

Address City Postal Code Country

Email*

Enter Email Confirm Email

Fax

Medical license number (or local equivalent)*

Consent*

I confirm, the physician indicated herewith, will be the contact person responsible for the management of the EAP with the local competent authority

Physician's specialty*

Prior experience with EAPs*

Yes
No

Physician awareness of data published on the requested drug*

Yes
No

PRIVACY STATEMENT: The provision of personal data by you may be necessary where in our legitimate interest in order for us to provide you with the requested services/information and for the performance of any contractual relationship with you. Because of our commitment to the protection of your personal data, we evaluate our privacy policies and procedures to implement improvements and refinements from time to time.

Please read the Privacy and Cookies Policy carefully in order to understand our views and practices regarding your personal data and how we will treat it.

Type of EAP

Type of EAP:*

Individual Patient
Group of Patients

If you selected "Individual Patient", please provide the following additional patient's information:

Patient Information

Note: Please, include only the information requested below avoiding any identifiable patients' information

Patient country of residence*

Diagnosis*

Additional information (medical history, concomitant pathologies and treatments)*

Gender*

Male
Female

Year of birth*

Enter full year e.g. 1980

Physician Declaration

Patient eligibility*

I confirm no treatment options are available for the above-mentioned patient(s) locally at the time of submitting this EAP request and inclusion in clinical trials was assessed
I confirm the benefit of using this treatment outweighs the risk for the patient

Physician eligibility*

I confirm I am qualified to administer the requested drug, in accordance with local laws and/or regulations governing EAPs

Helsinn will carefully evaluate your EAP Request, and will follow-up with you in writing, within 7 business days, to acknowledge receipt of the request, and for any additional information which may be needed.

Submission

Name*

First Last

Consent*

I confirm all the information included in this submission is correct

CAPTCHA

Name

This field is for validation purposes and should be left unchanged.

Early Access Program Request Form

Please submit your Early Access Program Request:

Physician information

Type of EAP

Patient Information

Physician Declaration

Submission