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Medical Information Request Form

This form is for HCPs only. Please fill in the medical information form below and click submit.

*Fields marked with asterisk are required

First Name*:

Last Name*:

Title*:

	MD		DO		NP
	RN		PharmD		RPh
	PA		PhD		Patient
	Other

Address*:

Address 2:

City:

State/Province:

Country*:

Zip/Postal Code*:

Phone*:

Fax*:

Email*:

Medical Information Request*:

Preferred Contact Method*:

Email Phone Mail Fax

Medical Information

In addition to the electronic submission form, you can call toll-free 877-634-VRTX (8789) for Medical Information requests.

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Tel 617-341-6100

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Last updated: Monday, May 7, 2012 - 10:23