MEDICAL INFORMATION FORM
Please fill in all information as accurately as possible providing relevant details where required.
Please note that the contact information provided in Section 1 will be used to allow Actavis to contact you with regard to your query. Please note that this information will not be passed on to any third party and information detailed in this form is treated as private and confidential.
If you have trouble filling in this form please contact:
Email: firstname.lastname@example.org Tel: 0044 1271 385 257
All sections marked with an asterix (*) must be completed