Multiple Sclerosis Trend Report Order Form Survey

Multiple Sclerosis Trend Report Order Form

To receive a copy of the report, please provide the required information in the form below.

By providing the information below you are giving Kikaku America International, who is the report publisher, and the publication sponsors, Teva Neuroscience and the National Multiple Sclerosis Society, permission to contact you about this publication or its products. To better understand how we intend to use the data you provide on this site, please read our Privacy Policy. We will not sell your information, and you will not receive anything from us that you have not agreed to receive. If you do not want to be contacted by either party, please check field 3 No.

Once the form is completed, please enter "Done" button at the end of the form.

1. Please provide the following information about yourself:

Please provide the following information about yourself: Name:
Company:
Address:
Address 2:
City/Town:
State:
ZIP/Postal Code:
Email Address:
Phone Number:

2. You are:

You are: Physician (Internist)

Neurologist

Medical Director (Other specialty)

HMO Medical Director

PPO Medical Director

HMO/PPO Medical Director

Mail Service/PBM/Specialty Pharmacy

Wholesale Distributor

Long-term Care Medical Director

Pharmacist

Clinical Pharmacist

Consultant Pharmacist

Director of Nursing

Geriatric Nurse Practitioner

Nurse Practitioner

Nurse

Practice Manager

Office billing expert

Case Manager

Nursing Home Facility

Assisted Living Facility

Managed Care Organization

Pharmacy Director (Clinical)

Pharmacy Director (Contracting)

Pharmacy Director (Outpatient)

Hospital Executive

Educational Institution

Medical Group Practice

Quality Assurance Staff Member

Nursing Home Administrator

Assisted Living Administrator

Pharmaceutical Company

Government

Consulting Firm

Publishing/Media/Research

Other

Other (please specify)

3. I would like to be contacted about other valuable information.

I would like to be contacted about other valuable information. Yes

If you have any questions please contact Peter at (202) 338-8256.

Thank you for your order. We will send you the The Multiple Sclerosis Trend Report: Perspectives from Managed Care, Providers, and Patients as soon as possible.

087124104/081282

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