May we please contact you?

Thank you for completing the prescreening questionnaire. Based on your answers, you or your patient have prequalified for the Rezdiffra™ Pregnancy and Lactation Registry. Next, we’ll need some additional information for the registry team to contact you.

The information you provide will only be shared with our registry team. This way, the registry team can contact you to discuss your or your patient’s eligibility for the registry in more detail.

It is important to remember that your or your patient’s registry participation is completely voluntary, and you or your patient can choose not to participate at any time. If you or your patient choose not to take part, please inform the registry team.

Please provide your contact information in the form below. All fields marked with an (*) are required.

* First Name:

* Last Name:

* Gender:

* Email Address:

* Phone Number:

* Is this a mobile device?:

* May a registry team member contact you via SMS text message? (Message and data rates may apply.):

* * Can the registry team leave you a voicemail?:

Yes No

* What is the best time of day to contact you Monday through Friday?:

* How did you hear about the study?:

Do you agree to have a member of the ICON study team contact you to discuss the study in more detail?

* I agree to have the registry team contact me.

We are committed to keeping your personal information safe and secure. Please see our Privacy Notice.