Medical Inquiry | Catalyst Medical Information

Medical inquiry form

Please fill out the following form to submit a medical inquiry to Catalyst Pharmaceuticals for FYCOMPA, FIRDAPSE, or AGAMREE.

Contact Information

First Name*

Last Name*

Professional Designation*

Institutional Affiliation

Position in Insititution

NPI or Physician License Number

Street

City

State/Province*

Zip Code*

Phone*

Email*

Response Via*

Product*

Describe Request*

Please note that your personal information will be used by Catalyst Pharmaceuticals (“Catalyst”) to respond to your request. By submitting your information, you agree to Catalyst’s Privacy Policy, which will govern the collection, use, disclosure, and retention of your personal information. Please do not click “SUBMIT” unless you have read and agree with the terms of the Privacy Policy. By clicking “SUBMIT”, you agree that you have read, understand, and agree to these conditions.

(*) Mandatory fields

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