GSK

Medical Information Inquiry Request Form

The following form is to be used for Medical Information inquiries from Healthcare professionals. We understand that you would like to request information regarding GSK's licensed products and/or products in development.

Please complete the below fields and submit this form.
* Indicates a required field.

Responsive image

Country*:

Healthcare Professional's Name*:

Salutation/Degree:

Facility:

Phone:

Email*:

GSK Product Name*:

Submitter's Name*: (if different than HCP's Name above, otherwise enter NA):

Submitter's Email*: (if different than above, otherwise enter NA):

Responsive image

Please respond to this Medical Information Request By: (Choose all that apply)

Phone Email Schedule with GSK Medical Personnel

Responsive image

Specific medical inquiry/question*:

I confirm that this is an unsolicited request for information from GSK Medical Information.

I am not reporting an adverse drug reaction or product quality complaint via the medical inquiry form.

In order to handle your enquiry, we are required to record and maintain the personal information that you have provided to us. For more details on the processing of your personal information please read our Privacy notice

REQUEST MEDICAL INFORMATION

REQUEST MEDICAL INFORMATION

SuccessREQUEST MEDICAL INFORMATION

REQUEST MEDICAL INFORMATION

Thank you for you interest. Based on your location, we are going to direct you to our general GSK Professional site where you can log your request.

Success
REQUEST MEDICAL INFORMATION