eMIRF Form - Spring2021 endpoint

Congress Name

Name*

First NameLast Name

HCP Type*

HCP Credentials*

Street Address*

City*

State*

Country*

Email*

example@example.com

Phone Number*

Please enter a valid phone number.

Organization*

Product*

Inquiry*

Delivery Option*

Unless otherwise stated, all responses will be sent via email, if provided

Did the HCP specifically request an MSL follow-up?

Yes

Response(s) may include published literature which are subject to reporting in accordance with the Sunshine Act (Open Payments). Takeda is obligated to report HCP transfers of value to certain states and the federal government. Should literature with an assigned value be included in the response(s), how would you like us to fulfill the request:*

Data Privacy Notice: In order to respond to your request, it is necessary to collect and process the personal information you have provided to Takeda. This data will be provided to the appropriate departments within Takeda to address your inquiry. All information you provide will be retained in accordance with the latest applicable Data Protection laws for a period necessary to comply with the purposes for which your data has been provided. For more detailed information on how Takeda processes personal data, please refer to Takeda's Privacy Notice at https://www.takeda.com/privacy-notice

*denotes required field.

By hitting “submit”, you are confirming that your request(s) and/or question(s) was (were) not prompted or solicited by anyone at Takeda.