Today's Date: March 12, 2010

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Medical Information Request Form

A. Healthcare Professional Contact Information:

Full Name:

Mailing Address:

State:

Telephone Number (including area code):

Email:

Degree:

City:

Zip Code:

Fax Number:

Preferred Method of Response:

Phone Mail Email Fax

B. Medical Information Inquiry:

Products:

Inquiry:

To report an Adverse Event please contact Elan at 1-877-352-6477