Submit a Medical Inquiry | Astellas Medical Information

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Submit a Medical Inquiry - International

This form is only for Healthcare Providers outside the US. If you are a Healthcare Professional in the US with a question about an Astellas product, please click here. Use the form below to submit your medical inquiry to our Medical Information staff. You will be contacted via your preferred contact method within 2 business days.

* Indicates required fields

Conference Name * Conference Name cannot be blank
Product:* Please choose Product from the list Please Specify Astellas Product:* Other Product cannot be blank
Preferred Contact Method:* Please choose preferred contact option Email:* Email cannot be left blank please enter your email address Fax:* Please provide Fax
Salutation:* Salutation Required First Name:* First Name Cannot be blank Last Name:* Last Name Cannot be blank
Degree:* Please select Degree Please Specify Degree:* Please specify other Degree
Institution / Practice Name:* Please specify Institution
Address1:* Address cannot be left blank Address2:
City:* Please specify City Province/Territory:* Please specify State/Province
Postal Code:* Please provide Postal Code Country:* Please specify Country For Astellas US contact, please click here.
Phone:* Please provide phone number We require a contact telephone number in case we may need to clarify your inquiry prior to providing information. Extension:
Preferred Date of Callback:
Preferred Time of Callback :
Hour: Minute: Time:
Inquiry:* Inquiry cannot be left blank
Signature:* By signing, I certify this is an unsolicited request for medical information. Clear Signature
Cancel

All personal information will be kept confidential and will not be shared with any parties other than Astellas Pharma and their designated partners. View our full Privacy Policy.

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