Mayne Pharma - Samples Order Form

ACTIKERALL Support and Samples Order Form
Name*

First NameLast Name
Email
example@example.com
Clinic name*
Address
Number of samples requested*
Signature*

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I am a registered Australian healthcare professional that is able to prescribe prescription products.
I would like to be contacted by a Mayne Pharma representative for further information on ACTIKERALL (0.5% 5-FU & 10% Salicylic acid)
I would like to order ACTIKERALL patient booklets
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.

Please review the Full Product Information before prescribing.
Full Product Information is available from maynepharma.com/actikerall

ACTIKERALL^® is a registered trademark of Almirall S.A. ACTIKERALL is distributed by Mayne Pharma International Pty Ltd under licence from Almirall Hermal GmbH. Mayne Pharma International Pty Ltd, ABN 88 007 870 984. 1538 Main North Road, Salisbury South, SA 5106. Telephone: 1300 081 849. ACT0011. Date of preparation: Sept 2023.
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ACTIKERALL Support and Samples Order Form