Welcome to the UK medical information request form, this page is intended for use by UK healthcare professionals

Request medical information

IE-CHI-2100074. April 2022

Please note responses may not be saved if returning to the home screen

Request for Medical Information

Contact details:

Medical information requested:

Specific details of request

Any additional relevant details to your request

Requestor's signature

If you have any queries completing this, please email uk-msl@chiesi.com

Do not use this form to report Adverse Events. To report an Adverse Event, please contact our pharmacovigilance department on 0161 488 5555 or pv.uk@chiesi.com.

I declare that by signing this, I understand that my personal information will be used for the sole purpose of dealing with my request and will be handled in accordance with the ABPI Code of Practice for the Pharmaceutical Industry, the General Data Protection Regulation ((EU) 2016/679) and our Privacy Policy which can be found at https://www.chiesi.uk.com/privacy-policy.

IE-CHI-2100074. April 2022
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