Medical Information Request

This form is for U.S. healthcare providers only.

DO NOT report adverse events on this form.
Contact Allergan to report a suspected adverse event at 1-800-678-1605.

For inquiries in countries outside of the U.S., please refer to our Global Medical Information Contacts list.

For patients/caregivers, please consult with your physician or contact our Medical Information Department.

Please tell us what information you are requesting, being as specific as possible. If you have additional questions on other products, please submit another request form.

If the product of interest is not present, please contact our Medical Information Department.

The information you provide will be treated in accordance with Allergan's Privacy Policy.

Medical Information Request

Product

Product Strength

Full Name

Specialty

State of Licensure

State

Preferred Delivery Email Mail Phone Fax

Address

Address Line 2

City

Zip Code

Phone Number

Preferred Call Time

Fax

HCP Electronic Signature

Your signature confirms your question(s) was (were) not prompted or solicited by anyone at Allergan and that the wording above accurately states your question(s).