Contact / Enquiry Form

Fields marked with an asterisk (*) are mandatory.

Date

Title

ProfessorDrMrMrsMs

First name *

Surname *

Country *

Institution

Professional Speciality (if HCP)

Professional Email Address (if applicable) or Alternative Email Address *

Contact number *

Preferred method of contact

EmailTelephoneIn person (excluding sales)

Does this enquiry relate to an adverse event (AE) experienced with Leqembi® (lecanemab)? *

YesNo

If yes, please provide details (product, patient age, gender, initials, event description, batch number, patient CAP ID, other relevant information):

If no, please provide details of your enquiry:

Signature *

Sign above using your mouse, finger, or stylus.

Date

* mandatory fields