Mayne Pharma - Samples Order Form

Please request UROREC samples and patient resources here

Number of samples requested*

Signature*

Please select the urology patient resources you would like to receive:

	Printed version (to be mailed out)	Digital version (to be sent by email)
IPSS patient sheets
Bladder Diary patient sheets
UROREC patient information sheets

Would you like Mayne Pharma to provide any of the following clinical papers to you?

Alpha blockers and bladder outlet obstructionEfficacy of silodosinSilodosin use in real worldOther

Name*

First NameLast Name

Email*

example@example.com

Clinic name*

Address

I am a registered Australian healthcare professional that is able to prescribe prescription products.

I would like to receive other communications from Mayne Pharma including information on educational events and new products.

I would like to be contacted by a Mayne Pharma representative for further information on UROREC (silodosin).

By completing this sample request form, I consent to Mayne Pharma contacting me. My information will not be shared with a third party and I can opt out at any time by contacting au.enquiries@maynepharma.com.

Mayne Pharma complies with the Privacy Act 1988. Details of our privacy policy can be found at maynepharma.com/privacy-policy.

PBS Information: This product is not listed on the PBS.
For RPBS Information refer to PBS Schedule

Please review the Full Product Information before prescribing.

UROREC^® is sold by Mayne Pharma International Pty Ltd under license from Recordati Ireland, Ltd., Ringaskiddy, Ireland and Kissei Pharmaceutical Co., Ltd., Matsumoto, Japan. Mayne Pharma International Pty Ltd, ABN 88 007 870 984. 1538 Main North Road, Salisbury South, SA 5106. T: 1300 081 849. URO0101e_1. Date of preparation: Aug 2023.

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