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Patient Medical Questionnaire for Medication Requests

This questionnaire is intended to collect medical and legal information necessary for processing medication requests for rare diseases. Providing accurate information is essential for ensuring proper assessment and compliance with international healthcare regulations. Submission of this form does not guarantee medication availability or approval. The investigation fee is separate from the cost of any medications, which may have additional legal and logistical requirements. Please consult with your healthcare provider before proceeding with any medication requests.

First Name

Family Name

Date of Birth

Email Address

Mobile Phone Number

Gender

Gender
A
B
C
D

Nationality

Country of residence

Please upload copy of your valid Passport