[DRAFT] Aug 2021 Xarelto Starter Pack Sample Form

Please select the item(s) you would like to order

Xarelto 20mg Sample Pack (max 10 units)

1 pack contains 7 film coated rivaroxaban tablets

$ Free Quantity

Xarelto 15mg Sample Pack (max 10)

1 pack contains 7 film coated rivaroxaban tablets

$ Free Quantity

PBS codes A5 card

HCP materials

$ Free Quantity

Xarelto Prescriber Guide

HCP materials

$ Free Quantity

NVAF Patient Information Booklets

With easy to read font size! Patient booklets are available in English, Arabic, Mandarin & Vietnamese

$ Free

DVT & PE Patient Information Booklets

With easy to read font size! Patient booklets are available in English, Arabic, Mandarin & Vietnamese

$ Free

X-Set-Go Tear-off pad

HCP materials

$ Free Quantity

X-Set-Go Patient Brochure Insert NVAF

HCP materials

$ Free Quantity

X-Set-Go Patient Brochure Insert DVT + PE

HCP materials

$ Free Quantity

Yes, I would like to request a virtual or a face to face callNo, I am not interested
Preferred Date and Time
Preferred channel for contact
Viewing On-Demand contentAttending live virtual events
Privacy Consent

By completing this request form, I confirm my request of starter packs (samples) and materials and consent to Bayer Australia Ltd collecting, using, storing and disclosing the information provided by me on this form in accordance with the Privacy Consent Form that appears at the bottom of this form.
Doctor's Name *

First NameLast Name
Practice Address*

Practice Name

Practice Address

CityState / Province

Postal / Zip Code
Doctor's Email*
example@example.com
Date

DayMonthYear
Date
Signature*

Clear
Directions for appropriate use of product:
View Xarelto Product Information on TGA website
Supplier name: Bayer Australia Limited
Supplier address from which samples are supplied: c/o DHL Supply Chain 5 Millner Avenue Horsley Park NSW 2175 (Product Managers to check)
Yes, I confirm and consent
Should be Empty:

Prescriber and patient resources request form [DRAFT]