Early Access Programs Form

Please submit your Early Access Program Request:

Compound

Disease / condition to be treated

Physician information

Name

Surname

Institution (if any)

Address

City

County / State / Region

ZIP / postal Code

Country

Contact email address

Phone Number

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

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

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

Both options are required

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

Surname

I confirm all the information included in this submission is correct

CAPTCHA

About Us

Business

Technology

ESG

Patients

Patients

Early Access Programs Form

Physician information

Patient eligibility *

Physician eligibility *

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.

About Us

Business

Technology

ESG

Patients

Patients

Early Access Programs Form

Physician information

Patient eligibility *

Physician eligibility *

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.

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