Information Form

To receive your FREE APOKYN PATIENT INFORMATION KIT, please fill out the information below. Please note, all fields with "*" are required:

First Name: *
Last Name: *
Address 1: *
Address 2:
City: *
State: ALABAMAALASKAARIZONAARKANSASCALIFORNIACOLORADOCONNECTICUTDELAWAREDISTRICT OF COLUMBIAFLORIDAGEORGIAHAWAIIIDAHOILLINOISINDIANAIOWAKANSASKENTUCKYLOUISIANAMAINEMARYLANDMASSACHUSETTSMICHIGANMINNESOTAMISSISSIPPIMISSOURIMONTANANEBRASKANEVADANEW HAMPSHIRENEW JERSEYNEW MEXICONEW YORKNORTH CAROLINANORTH DAKOTAOHIOOKLAHOMAOREGONPENNSYLVANIARHODE ISLANDSOUTH CAROLINASOUTH DAKOTATENNESSEETEXASUTAHVERMONTVIRGINIAWASHINGTONWEST VIRGINIAWISCONSINWYOMING *
ZIP Code: *
Email Address:
I am a: choose one Patient Care Partner Healthcare Professional *

Patient and Care Partner Area This area to be filled out by Patients and Care Partners only. How did you hear about APOKYN? choose one Internet Product Literature My Doctor Parkinson's Disease Foundation/Organizations Other To better serve your needs for future communications, please answer the following questions: How old are you/is the person who has Parkinson's disease? choose one Under 45 45-54 55-64 Over 65 How long ago were you/was the person with Parkinson's disease diagnosed? choose one Less than 1 year 1-5 years 6-10 years Over 10 years How likely are you to ask a doctor about APOKYN? choose one Very likely Somewhat likely Somewhat unlikely Very unlikely I would like to order an APOKYN Patient Information Kit.   Would you/the person in your care like to receive future communications from Vernalis regarding Parkinson's disease?    Yes No

Healthcare Professional Area This area to be filled out by Healthcare Professionals only. I would like to order APOKYN Patient Information Kit(s). Quantity choose one 1 2 3 4 5 6 7 8 9 10 I would like to be contacted by a Vernalis Representative to discuss APOKYN. Yes No I would like to receive future communications from Vernalis regarding Parkinson's disease. Yes No My specialty is:

Vernalis respects your privacy and your information. Your information will only be used for internal purposes relating to Vernalis programs, products, and services. Vernalis will not sell or transfer your name, address, or email address to any other party for their own marketing use.

For additional information on how Vernalis handles your information, please read our privacy statement.