Compassionate Use/Managed Access Program

* Mandatory fields

Physician Identity
Please enter your last name
Please enter your first name
Please enter your specialty
Please enter your email address
Contact Details
Please select your country
Please enter your company/hospital
Please enter your address
Please enter your city, state
Please enter your phone number
Product Request
Please do not include any patient identifiers (e.g. patient name etc.)
Please fill in the Drug/product field
Please fill in the Dose/strength field
Please fill in the Duration of Treatment field
Please fill in the Quantity field
Please fill in the Disease / condition to be treated field
Please fill in the Rationale for request field
Please fill in the Additional information field
Security

The information about you collected through this form is used by Sanofi to handle your request. Fields with an asterisk are mandatory. Your data will be processed by Sanofi’s authorized services, and might be shared with other group affiliates or transmitted to external service providers processing your data on behalf of Sanofi. These affiliates or service providers may be located in countries which do not ensure the same level of personal data protection. In such case, Sanofi ensures that all necessary guarantees have been implemented to secure your personal data when transferred abroad. For more information on protection mechanisms implemented, please contact: Privacy-Office-Global@sanofi.com.

You have the right to access, rectify, and to object to the processing of your personal data, and from the date the General Data Protection Regulation is applicable (25 May, 2018), the right to obtain erasure of your personal data, as well as the right to data portability and the right to request restriction of the processing. To exercise your rights, please contact: Privacy-Office-Global@sanofi.com.